The cardiovascular risk of patients with carotid artery stenosis

It is commonly accepted that a relationship exists between coronary and carotid arterial disease, given that the prevalence of coronary artery disease (CAD) in patients with carotid stenosis is as high as 77%, depending on the population studied. Elevated cardiovascular (CV) risks are apparent in patients with either asymptomatic or symptomatic carotid stenosis. Patients with asymptomatic carotid stenosis are at about a three-fold higher risk of CV death/myocardial infarction compared with a matched population without carotid stenosis, and this risk may be even higher among patients with symptomatic carotid stenosis. Thus, antiplatelet and lipid-lowering therapies are indicated not only to prevent stroke, but also especially to lower elevated CV risks. Carotid revascularization has become well established in patients with symptomatic carotid stenosis, which is associated with significant absolute risk reductions in terms of recurrent stroke, but remains controversial for patients with significant but asymptomatic carotid stenosis. Carotid revascularization in those with asymptomatic carotid stenosis seems to principally benefit patients with specific clinical/imaging features indicating a high risk of stroke. Screening and treatment of asymptomatic CAD can be beneficial for patients with recently symptomatic carotid stenosis and especially for those for whom surgical or endovascular carotid revascularization is planned. Because evidence of the benefits afforded by prophylactic revascularization of asymptomatic carotid artery stenosis in all CABG candidates (in terms of reducing perioperative stroke) is lacking, it may be reasonable to restrict prophylactic carotid revascularization to patients at the highest risk of postoperative stroke, thus those with severe bilateral lesions or a history of prior stroke/transient ischemic event.     

Interventional Management of Asymptomatic Extracranial Carotid Stenosis

Carotid artery stenosis is a major risk factor for stroke and transient ischemic attack. Although carotid endarterectomy is the established gold standard for carotid revascularization, carotid artery angioplasty and stenting (CAS)—proven by large randomized clinical trials and rigorous registries and supported by improving stent designs, embolic protection, and increasing neurointerventionalist experience—is developing into a safer and more efficacious method of stroke prevention. Today, protected CAS is approved for symptomatic and asymptomatic patients with severe carotid stenosis with high surgical risk. We reviewed recently published data regarding new developments in the use of protected CAS, particularly in patients with carotid stenosis who are either asymptomatic or at low surgical risk.     

Combined carotid endarterectomy and coronary artery bypass grafting. A literature review.

This is a review article on the management of patients with both carotid and coronary artery lesions. Most authors agree that patients with symptomatic coronary and symptomatic carotid disease should be offered a combined operation (same anaesthetic) in the presence of unstable angina or left main stem coronary disease and staged operations in the presence of stable angina. Patients with symptomatic coronary disease and asymptomatic severe (greater than 80% stenosis) carotid disease should be offered the staged procedure not for preventing perioperative but late stroke. This statement is tentative and not supported by hard data. It should be revised when the results of the multicentre randomised studies of asymptomatic carotid stenosis become available. A prospective randomised study is required in patients with symptomatic coronary and asymptomatic severe unilateral and bilateral carotid stenosis (greater than 80%) in order to determine whether surgery in the carotid decreases the incidence of late stroke. It cannot be overemphasised that the team that does the carotid endarterectomy should have a good track record of combined mortality and morbidity of less than 5% for patients with TIA's and less than 3% for patients with asymptomatic carotid disease.     

Hybrid技术治疗冠心病合并严重颈动脉狭窄的临床疗效及安全性研究

目的回顾性分析颈动脉支架术(CAS)和冠状动脉旁路移植术(CABG)同期或分期Hybrid技术治疗冠心病合并严重颈动脉狭窄的临床疗效及安全性。方法入选2008年7月至2014年9月期间中国医学科学院阜外医院成人心脏外科收治的同期或分期实施CAS和CABG的冠心病合并严重颈动脉狭窄患者274例,依据两种手术是否同期实施分为两组:同期手术组(间隔≤7 d,n=35)和分期手术组(间隔7 d,n=239)。对两组患者的临床资料及预后进行比较分析。结果与同期手术组相比,分期手术组患者的搭桥数量、颈动脉支架植入个数以及肾动脉支架植入个数显著增加,而呼吸机辅助时间显著减少,差异均具有统计学意义(P0.05)。中位随访时间为45.6(28.1~65.4)个月,随访期间仅1例患者发生脑卒中而死亡。两组患者围手术期不良事件发生率间差异无统计学意义(P0.05)。截至随访终期,Cox模型分析结果显示,是否同期手术与患者复合终点事件发生率无明显相关性(OR=0.679,95%CI:0.12~3.72;P=0.66)。结论 CAS联合CABG是治疗冠心病合并严重颈动脉狭窄的一种安全、有效的微创策略。     

Associated vascular lesions in patients undergoing coronary artery bypass grafting

Atherosclerotic involvement of extracoronary arteries in patients undergoing myocardial revascularization can cause severe postoperative complications and increase postoperative mortality. Between January and November 1998, routine preoperative echo-Doppler study of carotid vessels, abdominal aorta and iliac-femoral arteries was performed in all patients undergoing coronary artery bypass grafting (CABG) at our institution, in order to assess the prevalence and the degree of associated vascular lesions. Correlations between echo-Doppler findings, angiographic patterns of coronary lesions and atherosclerotic risk factors were analyzed in all cases. Among 302 patients undergoing CABG, 186 (61.6%) had carotid disease, with a haemodynamically significant stenosis (>70%) of internal carotid in 31 (10.2%). Twenty-three patients had asymptomatic severe carotid disease. A significant correlation between severity of coronary disease and prevalence of severe carotid disease was found (p = 0.02). An abdominal aortic dilatation (diameter > 25 mm) was found in 20 cases (6.6%), with a diameter >35 mm in 7 patients (2.3%), 6 with triple-vessel coronary disease, and 1 with double-vessel disease. Atherosclerotic lesions of iliac-femoro-popliteal axis were found in 165 (54.6%) patients, with a strong correlation to the severity of coronary disease (p = 0.02); lesions were haemodynamically significant (> 70%) in 48 (15.8%) cases. Symptoms of carotid and peripheral vascular disease are no reliable predictors of perioperative risk in patients undergoing CABG. Non-invasive complete arterial investigation should be routinely performed in these patients, in order to plan the most suitable operative approach and to prevent perioperative vascular complications.     

Treatment strategies for carotid stenosis in patients at increased risk for surgery

The purpose of carotid revascularization is stroke prevention. The merits of carotid revascularization as well as the type of revascularization are dependent on the “natural risk” and the “revascularization risk.” In general, the natural risk of stroke in any patient with carotid stenosis (CS) is dependent on the symptomatic status of the patient and CS severity. Contemporary choices for carotid revascularization include carotid endarterectomy (CEA) and carotid artery stenting (CAS). Anatomical (hostile neck situations, severe bilateral CS, CEA restenosis) and clinical (severe cardiopulmonary diseases, prior cranial nerve injury) factors may increase the risk of CEA. Likewise, anatomical (complex aortic arch and brachiocephalic arterial anatomy, presence of thrombus, and heavy calcification) and clinical (need for heart surgery within 30 days) factors may increase the risk of CAS. Other factors such as the presence of symptomatic CS (transient ischemic attack or stroke within 6 months), decreased cerebral reserve, chronic kidney disease, and age older than 75 years may increase the risk of CEA and CAS. In general, symptomatic patients with severe CS exceed revascularization risk. In contrast, asymptomatic patients who are high risk for CEA should be considered for CAS because the natural risk of stroke should undergo careful assessment of baseline cognitive function, aortic arch and carotid artery anatomy, and likelihood of survival for 3 years. Patients who have normal cognitive function, favorable anatomy, and high likelihood of survival more than 3 years should be considered for CAS, whereas patients with multiple unfavorable features may be treated with optimal medical therapy, without revascularization.     

Management of severe bilateral carotid artery stenosis concomitant to severely symptomatic coronary arterial disease requiring coronary artery bypass grafting: a case-based review

Patients with significant carotid disease have an increased risk of stroke during coronary artery bypass grafting (CABG). However, due to its inherent risk and to the variety of mechanisms responsible for postoperative stroke, prophylactic carotid endarterectomy has an uncertain value, particularly in cases of asymptomatic unilateral carotid disease. In addition, the timing and sequence of coronary and carotid surgeries are controversial matters. Prophylactic carotid artery stenting is emerging as a potentially safer strategy. The major limitation of carotid stenting is the need for one month of dual antiplatelet therapy and the potential need to postpone CABG, which is not possible in patients with refractory unstable coronary syndromes. We describe the case of a patient with severe unstable coronary artery disease and bilateral carotid artery disease who was successfully managed with stenting of the most critical coronary lesion, staged bilateral carotid stenting, followed by CABG three weeks later.     

Contemporary management of concomitant carotid and coronary artery disease

The best approach to the management of concomitant severe carotid and coronary artery disease remains unanswered. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend carotid endarterectomy (CEA) in asymptomatic carotid stenosis of ≥ 80% either prior to or combined with coronary artery bypass surgery (CABG). Currently, there is no consensus as to which surgical approach is superior. More recently, carotid artery stenting (CAS) prior to CABG is emerging as an alternative option with promising results in asymptomatic patients considered 'high risk' for CEA. A <3% composite event rate has been set as a benchmark for isolated CAS or CEA in asymptomatic patients by the ACC/AHA; however, most CEA or CAS studies in patients requiring concomitant CABG have shown event rates ranging from 10-12%. This review examines the available data on carotid revascularisation in relation to CABG surgery to aid in the risk-benefit decision analysis in this controversial area.     

Combined carotid and coronary artery surgery: early and late results.

Patients with coronary artery disease can exhibit substantial vascular involvement; and vascular patients have a high incidence of coronary disease. Combined coronary artery bypass grafting (CABG) and treatment of extracranial cerebrovascular disease was performed in 52 patients, presenting strong indications for surgical treatment of coronary artery disease and symptomatic carotid disease and/or asymptomatic carotid bruit that reflected an ulcerative lesion or stenosis exceeding 75%. Overall hospital mortality was 3.8%. Clinical presentation determined the risk of the combined procedure: early mortality was much higher in urgent and emergency cases than in elective cases. Eight-year actuarial survival was 86%. This group of patients was compared with staged procedures in 45 patients (including carotid endarterectomy followed by CABG several weeks later) and with 42 patients who underwent coronary artery bypass in the presence of carotid bruits. Both early cardiac complications in the former group and neurologic complications in the latter were significantly more frequent than in combined procedures. Combined procedures can be performed with acceptable risk and with encouraging long-term results also in this special group of patients; they may improve the long-term prognosis of patients with diffuse atherosclerosis much more.     

Lessons from the SYNTAX trial

Despite the fact that CABG is the standard of care for patients with multivessel coronary arteries and/or left main stem stenosis, PCI has become a rival to CABG in patients with multivessel coronary artery disease or left main disease. However, the need for repeat revascularization, in-stent stenosis and thrombosis remain the achilis heal of PCI. SYNTAX trial randomized patients with left main disease and/or three-vessel disease to PCI with TAXus stent or CABG with the concept that PCI is not inferior to CABG. At 1 and 2 years follow up, MACCE was significantly increased in PCI patients mainly attributed to increased rate of repeat revascularization; however, stroke was significantly more with CABG. The composite safety endpoint of death/stroke/MI was comparable between the 2 groups. Therefore the criterion for non-inferiority was not met. What we learn from SYNTAX is that multi disciplinary team approach should be the standard of care when recommending treatment in more complex coronary artery disease. SYNTAX makes interventionists and surgeons come together, it may set the benchmark for MVD revascularization. PCI and CABG should be considered complementary rather than competitive revascularization strategies. There is no substitute for sound clinical judgment that takes into account the patient’s overall clinical profile, functionality, co-morbidities, as well as the patient’s coronary anatomy. The SYNTAX Score should be utilized to decide on treatment of patients with LM/MVD. Patients with low and intermediate score can be treated with PCI or CABG with equal results. Those with high score do better with CABG. SYNTAX trial showed that 66% of patients with 3VD or LMD are still best treated with CABG. In the remaining 1/3 of patients with low syntax score, PCI may be considered as an alternative to surgery. Finally, medical treatment should be optimized in patients going for CABG.     

Combined carotid endarterectomy and myocardial revascularization: personal experience

A significant percentage of patients undergoing myocardial revascularization suffer from extracranial cerebrovascular disease; recognition of such combined lesions identifies patients at risk for cerebrovascular accidents during the cardiac procedure. Simultaneous or staged coronary artery bypass graft (CABG) and carotid endarterectomy operations have been performed for the last 20 years, however, the clinical indications and the timing of the procedures remain controversial issues. Between November 1988 and January 1994, 1122 patients underwent myocardial revascularization at our Institute and in 35 cases (3.7%) carotid endarterectomy was simultaneously performed; 502 isolated carotid endarterectomies were performed in the same period. Trivascular coronary artery disease was found in 27 cases and low ejection fraction in six. Each patient received an average of 3.7 coronary grafts. Hospital mortality was 5.7% and major neurologic morbidity 2.8%. We believe that a simultaneous approach is recommended in patients with unstable angina and symptomatic carotid artery disease; in patients with a critical but asymptomatic carotid artery stenosis the indication for operation is subject to individual clinical judgment.     

Exploratory hierarchy and surgical indications for carotid surgery in patients with coronary disease

The major cause of death from carotid artery surgery (1.2% in 1984 in this series) is still coronary disease and myocardial infarct. A series of 50 patients were randomly selected for detailed study of post-operative cardiologic complications and the following sequelae were noted: mortality = 1 myocardial infarct; morbidity = 1 myocardial infarct, 3 documented anginal pains, 8 repolarization disorders, 4 benign ventricular arrhythmias. Analysis of these complications and a literature review demonstrated: the high frequency of combined carotid artery and coronary artery stenosis even in asymptomatic patients (25 to 40% of cases); the elevated percentage of complications in patients with symptomatic coronary disease (mortality risk multiplied by ten), hypertension or arterial disease; the low effect of age taken alone as risk factor. Pre-operative explorations to detect angina, particularly when latent and asymptomatic, should include a questionnaire, strict patient clinical examination and detailed reading of electrocardiogram tracings. An effort test should be performed as a function of results and patients' medical history and when positive should lead to coronarography in patients under 70 in good general condition, and when doubt persists after the effort tests. The indication for surgical treatment is dependent on results of these explorations: Carotid artery surgery (stenosis with high cerebral risk) should be performed under pre- and post-operative myocardial protection in patients with coronary artery disease who are too old or inoperable for cardiac reasons. Simultaneous myocardial and cerebral revascularization in the presence of severe lesions and at equivalent risk of progression. First intention carotid artery surgery for bilateral stable lesions with subsequent simultaneous myocardial and cerebral revascularization. First intention carotid artery surgery in case of cerebral ischemia with coronary artery shunt surgery at a later stage. Improved exploration of patients and close cooperation between cardiologists, anaesthetists and surgeons should allow patients at high risk to be operated upon under improved conditions of safety.     

冠状动脉旁路移植术和药物支架植入术远期疗效的比较

目的比较冠心病患者非药物治疗手段冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）术后的桥血管和支架的再通率。方法CABG术后和药物支架植入术后再次出现心绞痛症状的冠心病患者各40例,其年龄、性别、心肌梗死、高血压、高脂血症、心功能不全、脑卒中、药物治疗病史具有可比性。通过冠状动脉造影术比较两组患者的桥血管和药物支架的效率和寿命的远期效果。结果与行CABG患者的桥血管比较,行PCI患者的药物支架远期狭窄或者闭塞率降低34．3％。与行CABG患者的左乳内动脉（LIMA）桥血管比较,行PCI患者的左前降支的药物支架远期狭窄或者闭塞率降低14．8％。与行CABG患者的左回旋支和右冠状动脉静脉桥血管比较,行PCI患者的左回旋支以及右冠状动脉的药物支架远期狭窄或者闭塞率降低49．8％。结论冠状动脉药物支架植入术的远期通畅率较CABG明显增高,冠状动脉药物支架植入术的药物支架的效率和寿命要优于CABG的桥血管。     

The Current State of Left Main Percutaneous Coronary Intervention

Purpose of Review

While coronary artery bypass grafting (CABG) remains the standard of care, advances in stenting technology and procedural technique are changing the role of percutaneous coronary intervention (PCI) in the treatment of severe left main coronary artery (LMCA) disease. We review contemporary evidence comparing PCI and CABG for the treatment of severe LMCA disease, discuss optimal techniques during left main PCI, and provide guidance on studied revascularization strategies within specific patient subgroups.

Recent Findings

Results from randomized control trials of patients treated with PCI or CABG for severe LMCA disease demonstrate comparable short- and mid-term rates of death, myocardial infarction (MI), and stroke, but increased rates of repeat or target-vessel revascularization after PCI. Though extended follow-up data has suggested lower long-term rates of MI and stroke in patients with severe LMCA disease treated with CABG, results from patients undergoing PCI with second-generation drug-eluting stents (DES) demonstrate non-inferiority in these outcomes. These findings are generalizable to patients with severe LMCA disease having low to intermediate anatomic complexity. Intravascular ultrasound and double kissing (DK) crush stenting also reduce adverse event rates among patients undergoing left main PCI and improve long-term outcomes.

Summary

In patients with severe LMCA disease having low to intermediate anatomic complexity, both CABG and PCI with second-generation DES are effective methods of revascularization with comparable long-term rates of death, MI, and stroke. The roles of multi-vessel coronary artery disease and anatomic complexity on long-term outcomes after CABG or PCI for severe LMCA disease remain under investigation.

     

无症状重度颈动脉狭窄应是血管重建术的适应证吗?

随着卒中药物预防的不断改善,无症状颈动脉狭窄患者同侧卒中风险已等于甚至低于随机对照试验中的血管重建术组.在这种情况下,无症状重度颈动脉狭窄还是血管重建术的适应证吗?文章介绍了不同学者的观点.

Abstract：

With the continuous improvement of drag for stroke prevention, ipsilateral stroke risk in patients with asymptomatic carotid stenosis has been equal to or lower than that in the revascularization group in randomized controlled trials. Under this condition, is the asymptomatic severe carotid stenosis an indication for revascularization? This article introduces the views of different researchers.     

无症状重度颈动脉狭窄应是血管重建术的适应证吗?

随着卒中药物预防的不断改善,无症状颈动脉狭窄患者同侧卒中风险已等于甚至低于随机对照试验中的血管重建术组.在这种情况下,无症状重度颈动脉狭窄还是血管重建术的适应证吗?文章介绍了不同学者的观点.     

Update Karotisstenose

Stenosis of the extracranial carotid artery is a treatable cause of ischemic stroke and can reliably be detected and graded by vascular ultrasound. The differentiation between symptomatic and asymptomatic stenosis, the perioperative risk and the estimated life expectancy of the patient guide the therapy. Therapy is based on an optimal treatment of cardiovascular risk factors and antiplatelet drugs. Revascularization using surgical carotid endarterectomy is efficient for the prevention of stroke in patients with a high grade symptomatic stenosis. Endovascular therapy using stent-protected angioplasty of the carotid artery is an alternative in patients with a higher surgical risk with low complication rates when performed in experienced centres. Patients with asymptomatic carotid artery stenosis are primarily treated conservatively and revascularization is indicated in patients with a low surgical and global cardiovascular risk.     

Asymptomatic carotid artery stenosis

Opinion statement Severe asymptomatic carotid stenosis is associated with a stroke risk of approximately 2% per annum. Aggressive management of risk factors is recommended, including cessation of smoking, and treatment of hypertension, diabetes, and hypercholesterolemia. Patients should be treated with antiplatelet agents. Carotid endarterectomy (CEA) in patients with greater than or equal to 60% stenosis reduces the risk of stroke by approximately 1% per annum overall. The benefit is greatest for men and younger patients. There may be no benefit for women or for older patients. Carotid angioplasty and stenting is not recommended as an alternative to CEA until there is clinical trial evidence of efficacy in asymptomatic stenosis, except in some patients with technical contraindications to CEA. There is no evidence that patients with asymptomatic severe carotid stenosis should undergo carotid revascularization prior to other surgical procedures, including coronary bypass surgery.     

Early and late results of coronary angioplasty and bypass in octogenarians

Early and late results were evaluated for octogenarians undergoing first time revascularization with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). The study group consisted of 142 patients with CABG and 53 with PTCA. The groups with PTCA and CABG differed with respect to number of patients with angina class III to IV (92 and 67%, respectively; p less than 0.001), number with 3-vessel disease (34 and 77%, respectively; p less than 0.001), presence of left main trunk disease (2 and 24%, respectively; p less than 0.001) and number with normal or mildly impaired left ventricular function (82 and 65%, respectively; p less than 0.034). The groups with PTCA and CABG had similar procedural complications, including myocardial infarction (6 and 4%, respectively) and stroke (0 and 4%, respectively). Hospital mortality was low (6% with CABG and 2% with PTCA). Three year survival, excluding hospital mortality, was 87% in patients with CABG and 81% in those with PTCA (p = 0.493). Octogenarians underwent revascularization procedures with relatively low morbidity and mortality. In regard to the excellent long-term survival, "very" elderly patients with severe coronary artery disease should be considered for revascularization despite advanced age.     

Revascularization of left main coronary artery disease

Coronary artery disease with left main stenosis is associated with the highest mortality of any coronary lesion. Studies in the 1970s and 1980s comparing coronary artery bypass grafting (CABG) and medical therapy showed a significant survival benefit with revascularization. In the angioplasty era, initial experience with percutaneous intervention was associated with poor clinical outcomes. As a result, percutaneous coronary intervention (PCI) was restricted to patients who were considered inoperable, or those with prior CABG with a functional graft to the left anterior descending or circumflex artery ("protected left main disease"). With the introduction of drug-eluting stents, there are new studies demonstrating comparable survival in patients who were revascularized using PCI and CABG, although percutaneous revascularization is associated with a higher rate of repeat revascularization. In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial, the combined incidence of death, myocardial infarction, and stroke was similar between the CABG and PCI groups; however, the stroke rate was higher in the CABG group. The degree and extent of disease as defined by the SYNTAX scoring system has allowed for stratification of risk and improved assignment of patients with left main stenosis to either PCI or CABG.