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Short-term outcomes after carotid artery stenting followed by open heart surgery were comparable with those after carotid endarterectomy and open heart surgery performed at the same time, in a retrospective study that compared three approaches with treating patients who had both severe carotid artery disease and coronary artery disease.
However, after 1 year, staged carotid artery stenting and open heart surgery (CAS-OHS) "appears to be a better choice," with a significantly lower risk in the primary composite endpoint of death, stroke, or myocardial infarction, reported Dr. Mehdi H. Shishehbor and his coauthors (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.03.094]).
The primary composite endpoint after undergoing CAS-OHS or combined carotid endarterectomy and OHS (CEA-OHS) were similar in both groups.
The third approach studied was carotid endarterectomy (CEA) followed by open heart surgery (staged CEA-OHS), which had the least favorable outcomes of all three approaches, with a "substantial risk of interstage MI," they reported. This approach, therefore, "should be avoided if possible," they concluded in the studywhich was published online on July 31, in the Journal of the American College of Cardiology Cardiovascular Interventions. Dr. Shishehbor is director of endovascular services in the Miller Family Heart and Vascular Institute at the Cleveland Clinic.
The study evaluated outcomes among 350 patients with severe carotid artery stenosis and were candidates for OHS, who underwent carotid revascularization within 90 days of having open heart surgery, at the Cleveland Clinic from 1997 to 2009: 45 had staged CEA-OHS, 195 had combined CEA-OHS, and 110 has staged CAS-OHS. Most of the open heart surgeries were coronary artery bypass grafting procedures.
Based on their analyses, they determined that in the short term, the composite endpoint was similar between those in the staged CAS-OHS group and those in the combined CEA-OHS group – although those in the CAS-OHS group had more MIs, most of which were between the procedures, and those in the combined CEA-OHS group has more perioperative strokes.
Of all three approaches, short-term outcomes were worse in the staged CEA-OHS group, because of the significantly higher risk of interstage MIs.
After 1 year, those in the staged CAS-OHS group had a significantly lower risk of the composite outcomes, compared with the other two groups: a 65% lower risk, compared with those in the combined CEA-OHS group; and a 67% lower risk, compared with those in the staged CAS-OHS group. The risk in the composite outcomes after 1 year in the two CEA groups was similar. Mortality after 1 year was similar in the three groups.
"In choosing between staged CAS-OHS and combined CEA-OHS, the increased risk of interstage MI with the former and perioperative stroke with the latter are important considerations despite similar risks for the early composite endpoint," the authors noted.
"Our study shows that carotid stenting followed by open heart surgery should be the first line strategy for treating patients with severe carotid and coronary disease, if the three- to four-week wait between procedures is clinically acceptable," Dr. Shishehbor said in a statement issued by the Cleveland Clinic. Although there has never been a randomized trial to determine what the best approach is for the types of patients in the study, "the evidence in this study may be enough to change practice," he added.
In fact, as a result of the study findings, changes are being made to the way patients with severe carotid and coronary artery disease are being managed at the Cleveland Clinic, and "we are collaborating across disciplines to identify the lowest risk treatment option for each patient," he added.
In the United States, currently, only 3% of patients with severe carotid and coronary artery disease are treated with staged carotid stenting followed by open heart surgery – compared with 31% of the patients in this study, the statement points out.
Although it was retrospective, "this study provides clarity in the management of patients with carotid and coronary disease requiring OHS," Dr. Mahmud and Dr. Reeves wrote in an accompanying editorial (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.07.011]).
Combined CEA-OHS is the optimum revascularization strategy for "patients presenting with an acute coronary syndrome requiring urgent coronary revascularization in whom waiting 3-4 weeks is not safe," although is it associated with more neurological ischemic events.
"However, for patients with a stable or an accelerating anginal syndrome who can wait 3-4 weeks to complete dual-antiplatelet therapy after carotid stenting, staged CAS followed by OHS leads to superior early and long term outcomes," they wrote.
Staged CEA followed by OHS should be avoided, as it "is associated with an increased short term (inter-stage myocardial infarction) and long term (mortality) hazard."
The study, they added, "suggests that the currently acceptable option of CEA prior to OHS actually endangers the patient leading to the highest ischemic event rate both early and late after OHS. These patients should either undergo combined CEA-OHS or be offered the option of CAS prior to OHS based on medical criteria, not reimbursement issues."
Dr. Ehtisham Mahmud and Dr. Ryan Reeves, of the division of cardiovascular medicine and the Sulpizio Cardiovascular Center, at the University of California, San Diego. Dr. Mahmud, chief of cardiovascular medicine at the center, disclosed potential conflicts of interest for Boston Scientific and Abbott Vascular (clinical trial research support), Cordis Corporation and Medicines Company (consulting), and Medtronic (speakers bureau). Dr. Reeves listed no disclosures.
Although it was retrospective, "this study provides clarity in the management of patients with carotid and coronary disease requiring OHS," Dr. Mahmud and Dr. Reeves wrote in an accompanying editorial (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.07.011]).
Combined CEA-OHS is the optimum revascularization strategy for "patients presenting with an acute coronary syndrome requiring urgent coronary revascularization in whom waiting 3-4 weeks is not safe," although is it associated with more neurological ischemic events.
"However, for patients with a stable or an accelerating anginal syndrome who can wait 3-4 weeks to complete dual-antiplatelet therapy after carotid stenting, staged CAS followed by OHS leads to superior early and long term outcomes," they wrote.
Staged CEA followed by OHS should be avoided, as it "is associated with an increased short term (inter-stage myocardial infarction) and long term (mortality) hazard."
The study, they added, "suggests that the currently acceptable option of CEA prior to OHS actually endangers the patient leading to the highest ischemic event rate both early and late after OHS. These patients should either undergo combined CEA-OHS or be offered the option of CAS prior to OHS based on medical criteria, not reimbursement issues."
Dr. Ehtisham Mahmud and Dr. Ryan Reeves, of the division of cardiovascular medicine and the Sulpizio Cardiovascular Center, at the University of California, San Diego. Dr. Mahmud, chief of cardiovascular medicine at the center, disclosed potential conflicts of interest for Boston Scientific and Abbott Vascular (clinical trial research support), Cordis Corporation and Medicines Company (consulting), and Medtronic (speakers bureau). Dr. Reeves listed no disclosures.
Although it was retrospective, "this study provides clarity in the management of patients with carotid and coronary disease requiring OHS," Dr. Mahmud and Dr. Reeves wrote in an accompanying editorial (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.07.011]).
Combined CEA-OHS is the optimum revascularization strategy for "patients presenting with an acute coronary syndrome requiring urgent coronary revascularization in whom waiting 3-4 weeks is not safe," although is it associated with more neurological ischemic events.
"However, for patients with a stable or an accelerating anginal syndrome who can wait 3-4 weeks to complete dual-antiplatelet therapy after carotid stenting, staged CAS followed by OHS leads to superior early and long term outcomes," they wrote.
Staged CEA followed by OHS should be avoided, as it "is associated with an increased short term (inter-stage myocardial infarction) and long term (mortality) hazard."
The study, they added, "suggests that the currently acceptable option of CEA prior to OHS actually endangers the patient leading to the highest ischemic event rate both early and late after OHS. These patients should either undergo combined CEA-OHS or be offered the option of CAS prior to OHS based on medical criteria, not reimbursement issues."
Dr. Ehtisham Mahmud and Dr. Ryan Reeves, of the division of cardiovascular medicine and the Sulpizio Cardiovascular Center, at the University of California, San Diego. Dr. Mahmud, chief of cardiovascular medicine at the center, disclosed potential conflicts of interest for Boston Scientific and Abbott Vascular (clinical trial research support), Cordis Corporation and Medicines Company (consulting), and Medtronic (speakers bureau). Dr. Reeves listed no disclosures.
Short-term outcomes after carotid artery stenting followed by open heart surgery were comparable with those after carotid endarterectomy and open heart surgery performed at the same time, in a retrospective study that compared three approaches with treating patients who had both severe carotid artery disease and coronary artery disease.
However, after 1 year, staged carotid artery stenting and open heart surgery (CAS-OHS) "appears to be a better choice," with a significantly lower risk in the primary composite endpoint of death, stroke, or myocardial infarction, reported Dr. Mehdi H. Shishehbor and his coauthors (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.03.094]).
The primary composite endpoint after undergoing CAS-OHS or combined carotid endarterectomy and OHS (CEA-OHS) were similar in both groups.
The third approach studied was carotid endarterectomy (CEA) followed by open heart surgery (staged CEA-OHS), which had the least favorable outcomes of all three approaches, with a "substantial risk of interstage MI," they reported. This approach, therefore, "should be avoided if possible," they concluded in the studywhich was published online on July 31, in the Journal of the American College of Cardiology Cardiovascular Interventions. Dr. Shishehbor is director of endovascular services in the Miller Family Heart and Vascular Institute at the Cleveland Clinic.
The study evaluated outcomes among 350 patients with severe carotid artery stenosis and were candidates for OHS, who underwent carotid revascularization within 90 days of having open heart surgery, at the Cleveland Clinic from 1997 to 2009: 45 had staged CEA-OHS, 195 had combined CEA-OHS, and 110 has staged CAS-OHS. Most of the open heart surgeries were coronary artery bypass grafting procedures.
Based on their analyses, they determined that in the short term, the composite endpoint was similar between those in the staged CAS-OHS group and those in the combined CEA-OHS group – although those in the CAS-OHS group had more MIs, most of which were between the procedures, and those in the combined CEA-OHS group has more perioperative strokes.
Of all three approaches, short-term outcomes were worse in the staged CEA-OHS group, because of the significantly higher risk of interstage MIs.
After 1 year, those in the staged CAS-OHS group had a significantly lower risk of the composite outcomes, compared with the other two groups: a 65% lower risk, compared with those in the combined CEA-OHS group; and a 67% lower risk, compared with those in the staged CAS-OHS group. The risk in the composite outcomes after 1 year in the two CEA groups was similar. Mortality after 1 year was similar in the three groups.
"In choosing between staged CAS-OHS and combined CEA-OHS, the increased risk of interstage MI with the former and perioperative stroke with the latter are important considerations despite similar risks for the early composite endpoint," the authors noted.
"Our study shows that carotid stenting followed by open heart surgery should be the first line strategy for treating patients with severe carotid and coronary disease, if the three- to four-week wait between procedures is clinically acceptable," Dr. Shishehbor said in a statement issued by the Cleveland Clinic. Although there has never been a randomized trial to determine what the best approach is for the types of patients in the study, "the evidence in this study may be enough to change practice," he added.
In fact, as a result of the study findings, changes are being made to the way patients with severe carotid and coronary artery disease are being managed at the Cleveland Clinic, and "we are collaborating across disciplines to identify the lowest risk treatment option for each patient," he added.
In the United States, currently, only 3% of patients with severe carotid and coronary artery disease are treated with staged carotid stenting followed by open heart surgery – compared with 31% of the patients in this study, the statement points out.
Short-term outcomes after carotid artery stenting followed by open heart surgery were comparable with those after carotid endarterectomy and open heart surgery performed at the same time, in a retrospective study that compared three approaches with treating patients who had both severe carotid artery disease and coronary artery disease.
However, after 1 year, staged carotid artery stenting and open heart surgery (CAS-OHS) "appears to be a better choice," with a significantly lower risk in the primary composite endpoint of death, stroke, or myocardial infarction, reported Dr. Mehdi H. Shishehbor and his coauthors (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.03.094]).
The primary composite endpoint after undergoing CAS-OHS or combined carotid endarterectomy and OHS (CEA-OHS) were similar in both groups.
The third approach studied was carotid endarterectomy (CEA) followed by open heart surgery (staged CEA-OHS), which had the least favorable outcomes of all three approaches, with a "substantial risk of interstage MI," they reported. This approach, therefore, "should be avoided if possible," they concluded in the studywhich was published online on July 31, in the Journal of the American College of Cardiology Cardiovascular Interventions. Dr. Shishehbor is director of endovascular services in the Miller Family Heart and Vascular Institute at the Cleveland Clinic.
The study evaluated outcomes among 350 patients with severe carotid artery stenosis and were candidates for OHS, who underwent carotid revascularization within 90 days of having open heart surgery, at the Cleveland Clinic from 1997 to 2009: 45 had staged CEA-OHS, 195 had combined CEA-OHS, and 110 has staged CAS-OHS. Most of the open heart surgeries were coronary artery bypass grafting procedures.
Based on their analyses, they determined that in the short term, the composite endpoint was similar between those in the staged CAS-OHS group and those in the combined CEA-OHS group – although those in the CAS-OHS group had more MIs, most of which were between the procedures, and those in the combined CEA-OHS group has more perioperative strokes.
Of all three approaches, short-term outcomes were worse in the staged CEA-OHS group, because of the significantly higher risk of interstage MIs.
After 1 year, those in the staged CAS-OHS group had a significantly lower risk of the composite outcomes, compared with the other two groups: a 65% lower risk, compared with those in the combined CEA-OHS group; and a 67% lower risk, compared with those in the staged CAS-OHS group. The risk in the composite outcomes after 1 year in the two CEA groups was similar. Mortality after 1 year was similar in the three groups.
"In choosing between staged CAS-OHS and combined CEA-OHS, the increased risk of interstage MI with the former and perioperative stroke with the latter are important considerations despite similar risks for the early composite endpoint," the authors noted.
"Our study shows that carotid stenting followed by open heart surgery should be the first line strategy for treating patients with severe carotid and coronary disease, if the three- to four-week wait between procedures is clinically acceptable," Dr. Shishehbor said in a statement issued by the Cleveland Clinic. Although there has never been a randomized trial to determine what the best approach is for the types of patients in the study, "the evidence in this study may be enough to change practice," he added.
In fact, as a result of the study findings, changes are being made to the way patients with severe carotid and coronary artery disease are being managed at the Cleveland Clinic, and "we are collaborating across disciplines to identify the lowest risk treatment option for each patient," he added.
In the United States, currently, only 3% of patients with severe carotid and coronary artery disease are treated with staged carotid stenting followed by open heart surgery – compared with 31% of the patients in this study, the statement points out.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
Major finding: Short-term outcomes among patients undergoing carotid revascularization and open heart surgery were comparable among those who had carotid artery stenting followed by open heart surgery and those who had the combined procedure of carotic endarterectomy and surgery at the same time. But after 1 year, the former approach was associated with more favorable outcomes.
Data source: A retrospective study that evaluated outcomes in 350 patients who had carotid artery stenting or carotid endarterectomy before open heart surgery, or carotid endarterectomy at the same time as open heart surgery.
Disclosures: Dr. Shishehbor is a speaker and consultant for Abbott Vascular, Medtronic, and GORE, but waived all compensations for this study. Another author disclosed serving as a consultant to Boston Scientific, GORE, Medtronic, Endologix, and Vessix Vascular. Nine authors had no disclosures. The REDCap project is supported by National Center for Research Resources/National Institutes of Health.
