Staged carotid stenting, open heart surgery may improve outcomes

When it comes to managing severe carotid disease accompanied by coronary artery disease, staged carotid artery stenting and open heart surgery (CAS-OHS) yielded significantly better outcomes the first year after treatment compared with combined carotid endarterectomy and OHS (CEA-OHS) and staged CEA-OHS, according to a study published in the Aug. 6 issue of the Journal of the American College of Cardiology.

But the study also found that in the short term, staged CAS-OHS and combined CEA-OHS were both associated with a similar risk of mortality, stroke or heart attack. Staged CAS-OHS and combined CEA-OHS also led to more favorable short-term outcomes than staged CEA-OHS.

The researchers, led by Medi H. Shishehbor, DO, of the Cleveland Clinic in Ohio, followed 350 carotid revascularization patients who had OHS within 90 days at the Cleveland Clinic between 1997 and 2009. Most patients had severe carotid artery stenosis diagnosed by a routine ultrasound. For study purposes, OHS was considered to be either isolated CABG, CABG combined with other cardiac procedures or non-CABG heart surgery.

A stroke history was more common in CAS-OHS patients, so their OHS was more complex.

As the primary endpoint, the authors chose the combination of all-cause death, stroke and MI.

One year after CAS-OHS, the risk of the composite outcomes was lower with CAS-OHS compared with combined CEA-OHS (adjusted hazard ratio 0.35) and staged CEA-OHS (adjusted hazard ratio 0.33). Staged CEA-OHS and combined CEA-OHS, however, had similar composite outcomes risk. Mortality risk was the same for all three groups.

Data also revealed a significant higher risk of inter-stage MI with staged CEA-OHS based on the existence of coexisting severe coronary artery disease. In addition, patients who underwent a combined CEA-OHS had a higher risk for periprocedural stroke, which could explain the lower long-term mortality risk of staged CAS-OHS.

“The differential risk for stroke and MI seen with the two approaches is an important finding that should be discussed with the patient and considered when selecting the best approach to treat severe combined carotid and coronary artery disease,” the authors wrote.

The limitations of their research included that it was only a single-center study and was not a double-blind, randomized trial that could better account for confounding variables. However, the authors argued that their research highlighted important trends.

“In summary, available literature and the findings of our study demonstrate a consistent pattern in favor of the staged CAS-OHS strategy in this population,” they concluded. “Despite [these] data, in the United States, only three percent of patients with concomitant severe carotid and coronary artery disease undergo staged CAS-OHS, suggesting the need to consider revising our current strategies while we await a randomized trial.”