surgical approach in patients with concomitant carotid and coronary artery disease rashad mahmudov...
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Surgical Approach in Patients with Concomitant Surgical Approach in Patients with Concomitant
Carotid and Coronary Artery DiseaseCarotid and Coronary Artery Disease
Rashad MAHMUDOV Rashad MAHMUDOV
Central Hospital of Central Hospital of
Oilworkers, Baku-AzerbaijanOilworkers, Baku-Azerbaijan
Carotid artery disease: OverviewCarotid artery disease: Overview
StrokeStroke is the third leading cause of death is the third leading cause of death (795,000 people suffer a stroke, 164,000 (795,000 people suffer a stroke, 164,000 deaths/year) and leading cause of serious long-deaths/year) and leading cause of serious long-term disability in the U.S.term disability in the U.S.
AtherosclerosisAtherosclerosis accounts for up to one-third of accounts for up to one-third of all strokes.all strokes.
15-20% 15-20% of strokes is due to CAOD.of strokes is due to CAOD. 80% strokes 80% strokes occur in asymptomatic patients. occur in asymptomatic patients.
Cause of stroke and TIACause of stroke and TIA
EmbolusEmbolus Carotid atheromaCarotid atheroma Cardiac Cardiac
Atrial fibrillationAtrial fibrillation Mural thrombusMural thrombus Patent foramen ovalePatent foramen ovale
ThrombosisThrombosis Abnormality of vesselsAbnormality of vessels
AtherosclerosisAtherosclerosis Autiimmune diseaseAutiimmune disease VasculitisVasculitis Wall dissectionWall dissection
Abnormal clottingAbnormal clotting PolycythemiaPolycythemia ThrombocythemiaThrombocythemia HyperviscosityHyperviscosity Clotting disordersClotting disorders
• Inherited Inherited • acquiredacquired
Migraine?Migraine?
Prophylactic carotid revascularisation would
prevent 40 - 50% of perioperative stroke in asymptomatic patients.
Extracranial and Intracranial Extracranial and Intracranial circulationcirculation
The proximal internal carotid artery and the carotid bifurcation are most frequently involved
Risk factors for carotid stenosisRisk factors for carotid stenosis
AgeAge
Sex: man > womanSex: man > woman
Diabetes mellitusDiabetes mellitus
HypertensionHypertension
Smoking, alcoholSmoking, alcohol
DyslipidemiaDyslipidemia
Symptoms of carotid stenosisSymptoms of carotid stenosis
Temporary monocular blindness Temporary monocular blindness (embolization to the (embolization to the
ophthalmic artery).ophthalmic artery).
Transient Ischemic Attack (Transient Ischemic Attack (TIATIA).).
StrokeStroke (stroke risk (stroke risk symptomatic >>symptomatic >> asymptomatic). 70- asymptomatic). 70-
99% stenosis 2 yrs risk = 26%.99% stenosis 2 yrs risk = 26%.
A A carotid bruitcarotid bruit should be heard in the majority of patients should be heard in the majority of patients
with carotid stenosis > 75%.with carotid stenosis > 75%.
Evaluation of carotid artery stenosis Evaluation of carotid artery stenosis
Carotid duplex ultrasonographyCarotid duplex ultrasonography
Transcranial Doppler Transcranial Doppler
MR angiography (MRA)MR angiography (MRA)
CT angiography (CTA)CT angiography (CTA)
Carotid angiography Carotid angiography - the gold standard (1.3% - the gold standard (1.3%
neurological complication rate).neurological complication rate).
Carotid Artery StenosisCarotid Artery Stenosis
Carotid angiography
Treatment optionsTreatment options
Medical therapy (BMT)AspirinStatinHypertensionDiabetesDyslipidemia
Carotid artery stenting (CAS)
Carotid endarterectomy (CEA)
Best treatment --- ???
Concomitant Coronary and Concomitant Coronary and
Carotid Artery DiseaseCarotid Artery Disease
Concomitant Concomitant CoronaryCoronary andand CarotidCarotid Artery DiseaseArtery Disease
Patients referred for Patients referred for CABGCABG have a prevalence of have a prevalence of 17 - 22%17 - 22% for carotid stenosis for carotid stenosis > 50% > 50% and and 6 -12% for carotid stenosis 6 -12% for carotid stenosis > 80% (asymptomatic)> 80% (asymptomatic).. Conversely, significant CAD occurs Conversely, significant CAD occurs in nearly one third of pts with high-grade carotid stenosis who in nearly one third of pts with high-grade carotid stenosis who are being considered for CEA. are being considered for CEA.
The risk of The risk of perioperative strokeperioperative stroke after CABG: after CABG: 2% for carotid stenosis < 50% 2% for carotid stenosis < 50% 10% for carotid stenosis 50 – 80%10% for carotid stenosis 50 – 80% 19% for carotid stenosis greater than 80%.19% for carotid stenosis greater than 80%.
Plaque morphology: Plaque morphology: the presence of the presence of hypoechoichypoechoic or or echolucentecholucent plaque, plaque, plaque ulceration plaque ulceration etc.etc.
Prevalence of CS in CADPrevalence of CS in CAD
Tanimoto et al. Stroke, 2005.
Approach in combined CAD and CSApproach in combined CAD and CS
Fix the more Fix the more clinically active clinically active bed first in a staged bed first in a staged manner manner ????
Address the vascular bed with the Address the vascular bed with the tightest tightest stenosis stenosis ????
Revascularize the coronaries and the carotids Revascularize the coronaries and the carotids at at the same time the same time ????
Or…
Or…
Treatment options in concomitant CAD Treatment options in concomitant CAD and CSand CS
CEA ‘CEA ‘stagedstaged’ prior to CABG ’ prior to CABG
CEA ‘CEA ‘combinedcombined’ with CABG during the same ’ with CABG during the same anesthesia. anesthesia.
‘‘Reverse stagedReverse staged’, wherein CABG is performed ’, wherein CABG is performed prior to CEA (for emergency CABG situations prior to CEA (for emergency CABG situations only).only).
Study resultsStudy results Chiappini et alChiappini et al. 202 patients: The rate of perioperative stroke did not differ . 202 patients: The rate of perioperative stroke did not differ
significantly between the simultaneous CABG - CEA group and the sequential significantly between the simultaneous CABG - CEA group and the sequential operations group (operations group (6.4% vs 4.8%6.4% vs 4.8%). ).
Naylor Naylor et alet al.. 97 published studies (8,900 patients): the risk of stroke or death in 97 published studies (8,900 patients): the risk of stroke or death in CEA-CABG pts > than in pts undergoing staged procedures (CEA-CABG pts > than in pts undergoing staged procedures (8.7% vs. 6.1%8.7% vs. 6.1%). ).
Ricotta Ricotta et alet al.: increased incidence of stroke and death in patients undergoing .: increased incidence of stroke and death in patients undergoing the simultaneous CEA - CABG surgery approach.the simultaneous CEA - CABG surgery approach.
Hill et alHill et al.: combined rate of stroke and mortality of 13.0% with the joint .: combined rate of stroke and mortality of 13.0% with the joint procedure compared with 4.9% for CABG surgery alone.procedure compared with 4.9% for CABG surgery alone.
No study has shown the superiority of the combined procedure over the two-No study has shown the superiority of the combined procedure over the two-staged approach.staged approach.
High-risk subgroup with combinedHigh-risk subgroup with combinedcarotid and coronary artery diseasecarotid and coronary artery disease
Neurological symptoms (stroke / TIA).Neurological symptoms (stroke / TIA).
Bilateral carotid stenosis 80–99%.Bilateral carotid stenosis 80–99%.
Unilateral 50–99% carotid stenosis with Unilateral 50–99% carotid stenosis with
contralateral occlusion.contralateral occlusion.
Asymptomatic 80–99% carotid stenosis with Asymptomatic 80–99% carotid stenosis with
impaired cerebral perfusion reserve.impaired cerebral perfusion reserve.
Advantage of concomitant CEA-Advantage of concomitant CEA-CABGCABG
Lower costLower cost
One anesthesiaOne anesthesia
Shorter hospital stayShorter hospital stay
CEA continues to be CEA continues to be the gold standard the gold standard for treatment for for treatment for carotid stenosis. carotid stenosis. CAS has an expanding role for CAS has an expanding role for revascularization, particularly in high-risk patients.revascularization, particularly in high-risk patients.
Patients undergoing combined CABG-CEA enjoy Patients undergoing combined CABG-CEA enjoy excellent long-term excellent long-term freedom from strokefreedom from stroke, as well as, , as well as, good long-term survivalgood long-term survival. .
ConclusionsConclusions
The most recent guidelines suggest that CEA is The most recent guidelines suggest that CEA is recommended before or concomitant to CABG in recommended before or concomitant to CABG in patients with symptomatic carotid stenosis greater than patients with symptomatic carotid stenosis greater than 50% or asymptomatic carotid stenosis greater than 80%. 50% or asymptomatic carotid stenosis greater than 80%. If the procedures are to be staged, complication rates If the procedures are to be staged, complication rates are lower when carotid revascularization precedes are lower when carotid revascularization precedes CABG.CABG.
With the available observational studies, off-pump With the available observational studies, off-pump CABG may be considered in the setting of combined CABG may be considered in the setting of combined CEA-CABG when feasible.CEA-CABG when feasible.
ConclusionsConclusions
At last, At last,
the best management strategy for patients with the best management strategy for patients with concomitant surgical coronary artery disease in need of concomitant surgical coronary artery disease in need of CABG and significant carotid artery stenosis should be CABG and significant carotid artery stenosis should be based on individual patient characteristics, urgency of based on individual patient characteristics, urgency of revascularization, prioritization based on the revascularization, prioritization based on the symptomatic vascular territory, local expertise with an symptomatic vascular territory, local expertise with an integrated team approach by interventionalists, integrated team approach by interventionalists, neurologists and cardiothoracic surgeons, preferably in neurologists and cardiothoracic surgeons, preferably in high-volume centers.high-volume centers.
ConclusionsConclusions
Thank you Thank you for your attention !for your attention !