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Management of Carotid Artery Disease in Patients Undergoing
Cardiac Procedures
Marco Roffi Cardiology
University Hospital
Geneva, Switzerland
Disclosure
Speaker name:
.....Marco Roffi............................................................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s): unrestricted institutional reserach grannts from
Biotronik, Abbott Vascular, Medtronic, Boston Scientific, Biosensor
0
2
4
6
8
10
12
Overall Unilateral
50-99%
Bilateral
50-99%
Any
occlusion
Stroke
Stroke and Open Heart Surgery
Roffi M et al. Curr Cardiol Rep 2012;14:125-34.
Likosky DS et al. Stroke 2003;34:2830-4.
Bucerius J et al. Ann Thorac Surg 2003;75:472-8.
Stroke and Open
Heart Surgery
Combined CEA-CABG
• US population based study from 1993 to 2002
• N= 657‘877, combined CABG/CEA
– 1.1% 1993
– 1.6% 2002
Dubinsky RM and Lai SM. Neurology 2007;68195-7
EBM?
• CEA/CABG vs. CABG
→ stroke or death OR 2.25 (P<0.0001)
• No change over time in rate of perioperative stroke or death in the CEA/CABG group
Guidelines on Carotid Revascularization Prior to Open Hear Surgery
Roffi M and Cremonesi A. J Cardiovasc Surg 2013;54:47-54
Naylor AR et al. Eur J Vasc Endovasc Surg 2003;25:380-9
4.6% 4.6%
3.6%3.9%
2.7%
6.5%
2.0%
6.3%
0.9%
CEA+CABG CEA->CABG CABG->CEA
Death
Stroke
MI
Meta-Analysis 97 studies, 8972 procedures
30-days death/stroke/MI 10-12%
CEA/CABG vs. CAS/CABG
• US Nationwide Inpatient Sample
• Concomitant coronary and carotid revascularization 2000-2004
• Of the 27’084 procedure performed in the five-year period only 3.3% (N=887) CAS → CABG
Timaran CH et al. J Vasc Surg 2008;48:355-61
3.9%
2.4%
8.6%
6.9%
Stroke Death/stroke
CEA-CABG
CAS-CABG
P<0.001 P<0.001
Timaran CH et al. J Vasc Surg 2008;48:355-61
MIMI StrokeStroke DeathDeath Death, MI,
or Stroke
Death, MI,
or Stroke
00
55
1010
1515
2020
2525
3030
3535
30 Day Adverse Events, (%)30 Day Adverse Events, (%)
3.33.3
12.612.6
1.81.8
9.09.0
5.45.47.27.2
10.710.7
21.621.6
CS + OHS, (N = 56)CS + OHS, (N = 56)
CEA + OHS, (N = 112)CEA + OHS, (N = 112)
p = 0.06 p = 0.08 p = 0.65
p = 0.08
Ziada KM et al. AJC 2005;96:519-23
Carotid revascularization in Open Heart
Surgery (OHS) population (1997–2009)
Carotid
Endarterectomy (CEA)
Carotid Artery
Stenting (CAS)
Staged
CEA-OHS
Combined
CEA-OHS
Staged
CAS-OHS
90 days 90 days
The Cleveland Clinic Experience 1997-2009
Shishehbor et al, JACC 2013
Study End Points
Staged
CEA-OHS
Combined
CEA-OHS
Staged
CAS-OHS
Primary end point: Composite of death,
stroke and myocardial infarction (MI)
Secondary end points: death, stroke, MI
Interval death,
stroke, MI
Shishehbor et al, JACC 2013
Statistical Methods
Time to event analysis
Multiphase hazard function model*
Propensity score adjustment
*Blackstone, EH et al. Journal of the American
Statistical *Association 1986,81:615-624
Modulated renewal strategy
Results
Carotid revascularization and OHS, n=350
CEA, n=45 CAS, n=110
OHS
n=42
Combined
CEA-OHS
n=195
OHS
n=104
Interval deaths
n=3
Interval deaths
n=6
Shishehbor et al, JACC 2013
Three Group Comparison
Primary Composite end point
Adjusted HR
(95% CI) P value
Staged CAS-OHS vs.
Combined CEA-OHS 0.76 (0.33-1.76) 0.52
Early
phase
Staged CEA-OHS vs.
Combined CEA-OHS 3.74 (1.78-7.89) <0.001
Staged CAS-OHS vs.
Staged CEA-OHS 0.20 (0.08-0.52) <0.001
Shishehbor et al, JACC 2013
Primary Composite Endpoint
Shishehbor et al, JACC 2013
Roffi M et al. Curr Cardiol Rep 2012;14:125-34.
Management of Patients With Carotid Stenosis Undergoing CABG
Circulation 2007;116;2002-2004
No perfect solution
• High risk, independently of revascularization strategy
• Stroke multifactorial
• CEA/CABG has significant morbidity and mortality
• If the patient is stable from a coronary standpoint,
CAS → CABG is an attractive alternative to CEA/CABG
The purpose of carotid revascularization prior to open heart
surgery is not just perioperative stroke reduction
(much more) but long-term stroke prevention
Management of Carotid Artery Disease in Patients Undergoing
Cardiac Procedures
Marco Roffi Cardiology
University Hospital
Geneva, Switzerland
