Carotid Artery Stenting prior to Cardiac Surgery

Abstract

This thesis describes the strategy of the management and treatment of patients with concomitant significant carotid and coronary artery disease. The short and long term outcome of a single centre experience is reported and compared with general common practise. The author conducted different observational trials in order to provide more information to justify the institutional policy. More particularly, the use of embolic protection devices in asymptomatic patients is questioned, the optimal antiplatelet therapy is investigated and the use of CT perfusion to better understand individual cerebral hemodynamics is examined.

Patients with asymptomatic carotid stenosis undergoing CAS-CABG have a decreased stroke and death rate compared to those undergoing isolated CABG or CEA-CABG. CAS may be a safer carotid revascularization option for patients with asymptomatic carotid stenosis requiring CABG in terms of postoperative stroke prevention.

In patients with symptomatic carotid stenosis available data are confounding, therefore the preferred strategy remains unclear, however carotid revascularization will result incontestably in higher periprocedural complication rates. Although level I evidence would be ideal to determine the best treatment strategy for patients who require combined treatment of carotid and coronary arterial disease, the design and implementation of a multicenter randomised clinical trial has been proven impractical and unrealistic. The heterogeneity of patients with varying degrees of coronary and carotid artery disease and the preference of carotid intervention are the main limitations for such a trial. Nevertheless, when conceived, such a trial should compare isolated CABG (including on and off pump surgery) with CAS-CABG and CEA-CABG in symptomatic and asymptomatic patients separately.

Optimal treatment of patients with concurrent carotid and coronary artery disease remains unresolved despite extensive publications during the last 30 years. Although only 40% to 50% of strokes after CABG are ipsilateral to an existing carotid lesion, carotid revascularization is one of the few available options to reduce the excessive stroke and death rates in patients with combined disease.