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Expert: Patients with concomitant CAD, carotid artery disease should have conditions treated separately
HOLLYWOOD, Fla. — Patients with both CAD and carotid artery disease who need endovascular treatment or surgery should have each condition treated individually by specialists for each disease, an expert said at the International Symposium on Endovascular Therapy.
“Our approach to combined coronary and carotid disease should involve a close collaboration between the best disciplines to treat each disease, and individualized to the patient, their history and their anatomies,” said D. Christopher Metzger, MD, FACC, FSCAI, an interventional cardiologist at Wellmont CVA Heart Institute in Kingsport, Tennessee.
It is common for patients to have both diseases because the risk factors for them are the same, Metzger said, noting that screening before a procedure to treat one disease often reveals the other.
All patients with both conditions should have “aggressive medical therapy and risk factor modification,” he said.
However, when it comes to interventional procedures, “one person or discipline should not treat both [diseases] unless they are the best for both procedures, and both procedures are indicated,” Metzger said.
Once it is discovered that a patient has combined disease, factors to be considered for a treatment plan include who the patient presented to and for which disease, how the second disease was discovered, which disease requires more urgent action, how risky the second disease is, whether each disease would require treatment independent of the other and whether and how two interventions could be staged safely, he said.
“We have learned that routinely doing coronary procedures before noncardiac surgeries often does more harm than good,” Metzger said. “The combined risk of PCI and noncardiac surgery often exceeded the risk of proceeding with surgery. PCI, and to a lesser extent carotid artery stenting, requires uninterrupted dual antiplatelet therapy, which may delay surgery. Pre-surgery PCI is now recommended only for patients at high CAD risk, or patients who would have otherwise required PCI. We [carotid stenting operators] should consider a similar strategy.”
Therefore, he said, the carotid disease should “be treated by the best operator and the correct procedure based on careful assessment of patient and anatomy. This is not necessarily the person who found the disease and will ‘fix’ the other [during the same procedure]. Experience matters in carotid revascularization.”
He recommended a process of “elective staging,” noting that if one procedure can be safely deferred, it should be, so that the more serious condition receives the optimal treatment.
For example, he said, a patient with high-grade carotid disease and three-vessel stable CAD should have CAS followed by DAPT for 4 to 6 weeks, then CABG while on aspirin alone. A patient with unstable CAD requiring CABG or PCI with asymptomatic unilateral 85% carotid artery stenosis should have CABG or PCI first, then carotid stenting or carotid endarterectomy after recovery.
What should not be done, Metzger said, is for both diseases to be treated simultaneously for physician convenience, for low-volume carotid endarterectomy operators to perform carotid endarterectomy and CABG at the same time, for interventional cardiologists to perform routine unindicated carotid angiograms or a “drive-by” CAS procedure, and for low-volume interventional cardiologists to perform CAS even if they found the disease.
“Carotid disease should only have indicated revascularization procedures, done by experienced operators, doing the most appropriate procedure after a careful individualized evaluation,” he said. “This is even more true in patients with combined disease.” – by Erik Swain
Reference:
Metzger DC. Concurrent Session IV: Optimizing outcomes in carotid therapy. Presented at: International Symposium on Endovascular Therapy; Feb. 4-8, 2017; Hollywood, Fla.
Disclosure : Metzger reports receiving honoraria from Abbott Vascular, Cardiovascular Systems Inc., Cordis, Intact Vascular and TriVascular.