OUTCOME OF CAROTID ARTERY STENTING IN PATIENT WITH COMBINED CAROTID AND

CORONARY ARTERY DISEASE

Moh. Reza J. Pasciolly,1

Vishal Rashtogi,2 Atul Mathur,2 Ashok Seth,2

1 Former Fellowship Cardiovascular Intervention Fortis Escort Heart Institute and Research Center, New Delhi, India - Now Attending Intervention Cardiologist

Department Cardiology and Vascular Medicine, Al Ihsan Government General Hospital, Bandung, West Java Province, Indonesia.

2 Fortis Escorts Heart Institute, New Delhi, India

Disclosure

Speaker name:

MOHAMMAD REZA JUNIERY PASCIOLLY.

I do not have any potential conflict of interest

ABSTRACT

• Objective:

Carotid artery stenting has been accepted as a potential alternative to carotid endarterectomy in patients with significant carotid artery stenosis.

The objective of this study was to evaluate the feasibility, safety and short term outcome of Carotid artery stenting in patients with coexisting

symptomatic coronary artery disease.

ABSTRACT …2

• Methods:The medical records were retrospectively reviewed and carotid artery interventions in patients with coronary artery disease were selected.

Prospective registry of such patients was also maintained.

All procedures were done between January 2015 to March 2017 at Fortis Escorts Heart Institute and Research Center, Delhi. 57 patients satisfied

the eligibility criteria.

Inclusion criteria:1. Combined carotid and coronary artery disease ;2. Patients at high risk of CEA and having indication for

CAS,10

restenosis after CEA, contralateral carotid artery occlusion or laryngeal nerve palsy, bilateral carotid artery stenosis, previous radiation therapy or surgery on the neck, neck immobility, tracheostomy or tracheostoma, severe intracranial lesion, lesion inaccessible by surgery, advanced CAD example acute coronary syndrome, three vessels disease or left main disease, heart failure, severe aortic stenosis, left ventricular ejection < 30%, renal failure, planned CABG or valve replacement, chronic obstructive pulmonary disease, cardiac and pulmonary disease, planned peripheral vascular surgery, myocardial infarction within 6 weeks of the procedure, age older than 80 years

3. Adults > 18 years 4. Carotid angiography showed carotid stenosis > 50 % if

symptomatic and > 70 % if asymptomatic.

• Exclusion criteria 1. Stroke / TIA / Amaurosis fugax within the past 14 days

2. Severely disabled as a result of stroke or dementia

3. Complete occlusion of carotid artery

4. Severe calcification, tortuosity of carotid artery

5. Intracranial tumor or cerebral venous malformation.

• Criteria carotid stenosis measured with duplex ultrasound scanning and arch aortography, by NASCET method.

ABSTRACT

• Results:– 44 (77.2%) patients were male.

– The mean age of patients was 65±8 years. 40(71.9%) patients were neurologically asymptomatic.

– Symptomatic patient had predominant symptoms of chest pain, dyspnea, syncope/presyncope, dizziness, blurring of vision, paresis/paralysis. 47.4% patients had unilateral and 52.5% patients had bilateral carotid artery disease.

– Amongst all patients 59.6% had TVD, 17.5% had DVD, 14% had SVD & 8.8% patients had non critical CAD.

– Among them 38.6% patients underwent PCI, 33.3% patients underwent surgery, 17.5% patients underwent both PCI and surgery and 10.6% patients were managed medically.

– Only 1 patient died after procedure.

Table 1. Baseline characteristic patient before carotid stenting …1

Variable Mean (± SD) ,Percentage n (%);

n= 57

Age ( Years) 65 (± 8)

Male (%) 44 (77.2 %)

Sign & Symptoms

Chest Pain / Angina Pectoris (%) 32 (56.1 %)

Dyspnea (%) 22 (38.6%)

Dizziness* 41 (71.9 %)

Loss of Consciousness / Syncope (%) 21 (36.8 %)

Blurry Vision (%) 19 (33.3 %)

Weakness (%) 29 (50.9 %)

Paresis (%) 19 (33.3 %)

Paralysis (%) 8 (14 %)

Risk Factor :

Hypertension (%) 43 (75.4 %)

Diabetes Mellitus (%) 39 (68.4 %)

Dyslipidemia (%) 43 (75.4%)

Smoker / Ex-smoker (%) 21 (36.8 %)

* Dizziness included vertigo, disequilibrium, pre-syncope, Nonspecific dizziness (giddiness or confusion)

Variable Mean (± SD) ,Percentage n (%);

n= 57

Comorbid :

Renal Dysfunction (%) 9 (15.8 %)

History Myocardial Infraction (%) 37 (64.9 %)

History Neurologic dysfunction Stroke / TIA (%) 20 (35.1 %) / 10 (17.5 %)

History Heart Failure (%) 11 ( 19.3 %)

Other Peripheral Artery Disease (PAD):

Renal (%) 4 (7 %)

Illiac (%) 0 (0 %)

Superficial Femorals (%) 4 (7 %)

Below The Knee (%) 1 (1.8 %)

Aorta (Aneurism / Dissection) (%) 1 (1.8 %)

Renal & Subclavian (%) 1 (1.8 %)

No other PAD (%) 46 (80.7 %)

Others comorbid :

Cancer (%) 4 (7.0 %)

Asthma (%) 2 (3.5 %)

Arrhythmia (%) 1 (1.8 %)

No Co-morbid 50 (87.7 %)

History

CAS

CEA

8 (14.0%)

1 (1.8 %)

LV EF (%) 53,88(± 8,26) %

Table 1. Baseline characteristic patient before carotid stenting …2

Figure 1: Diagram shows common presenting features of symptomatic patients

Figure 2: Pie chart coronary angiography report

Figure 3 Pie chart shows plan of management

Table 2. Complication after Carotid Stenting in Hospital

Variable Percentage ;n= 57 (%)

Death 1 (1.8 %)

Myocardial Infarct 0

Stroke 1 (1.8 %)

Shock 1 (1.8 %)

Renal Failure 6 (10.5 %)

Heart Failure 0

Infection 1 (1.8 %)

Arrhythmia 1 (1.8 %)

Table 3. Follow up in 30 days complication patient after Carotid Stenting

Variable Percentagen = 56 (%)

Death 0

Myocardial Infarct 4 (7.0 %)

Stroke 1 (1.8%)

Renal failure 3 (5.3 %)

Other 0

Conclusion:

– CAS EPD should be used to reduce complication.

– No significant difference between complications during hospitalization and within 30 days of CAS was seen.

– Carotid artery stenting in patients with coexistent carotid and coronary artery disease is feasible and safe strategy with favorable short term outcome.

– Severe combined carotid and coronary artery disease can be managed safely by hybrid approach

• LIMITATION – This is small registry with retrospective date to analyse.

– No randomized trial comparing different treatment strategies forconcomitant carotid and coronary artery disease managementy hasbeen conducted till date so thus far reported series are prone toselection/reporting bias.

– Need More Data established surgical treatment (CEA-CABG,sequential/simultaneous), hybrid revascularization (CAS-CABG) isemerging as a viable therapeutic option.

– Need Larger studies, preferably multi-center,

THANK YOU

TERIMA KASIH

HATUR NUHUN

OUTCOME OF CAROTID ARTERY STENTING IN PATIENT WITH COMBINED CAROTID AND

CORONARY ARTERY DISEASE

Moh. Reza J. Pasciolly,1

Vishal Rashtogi,2 Atul Mathur,2 Ashok Seth,2

1 Former Fellowship Cardiovascular Intervention Fortis Escort Heart Institute and Research Center, New Delhi, India - Now Attending Intervention Cardiologist

Department Cardiology and Vascular Medicine, Al Ihsan Government General Hospital, Bandung, West Java Province, Indonesia.

2 Fortis Escorts Heart Institute, New Delhi, India