Staged carotid artery stenting shows superior late outcomes in open heart surgery patients

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In carotid artery stenosis patients undergoing open heart surgery, staged carotid artery stenting demonstrated to have the best outcomes compared to staged and combined carotid endarterectomy and open heart surgery. The results of the retrospective comparison conducted at the Cleveland Clinic appear online in the Journal of the American College of Cardiology.

The investigators set out to compare risk-adjusted outcomes of three approaches to carotid revascularisation in the open heart surgery population. They write: “Without randomised clinical trials, the best approach to managing coexisting severe carotid and coronary disease remains uncertain. Staged carotid endarterectomy followed by open heart surgery or combined endarterectomy and open heart surgery are commonly used. A recent alternative is carotid artery stenting.”

The researchers, led by Mehdi H Shishehbor, director of Endovascular Services in the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic, examined the short- and long-term outcomes of 350 patients who underwent a carotid revascularisation procedure within 90 days of a planned open heart surgery at Cleveland Clinic between January 1997 and August 2009. The study population consisted primarily of patients who were found to have severe carotid artery disease as part of their evaluation prior to open heart surgery.

Of the procedures, 45 were staged endarterectomy-open heart surgery, 195 were combined endarterectomy-open heart surgery and 110 were staged carotid artery stenting-open heart surgery. The primary composite endpoint of the study was all-cause mortality, stroke, and myocardial infarction. Staged carotid stenting-open heart surgery patients had higher prevalence of prior stroke (p=0.03) and underwent more complex open heart surgery. Therefore, propensity score adjusted multiphase hazard function models with modulated renewal to account for staging, and competing risks were used.

Using propensity analysis, staged carotid artery stenting-open heart surgery and combined endarterectomy-open heart surgery had similar early hazard phase composite outcomes while staged endarterectomy-open heart surgery incurred the highest risk driven by inter-stage myocardial infarction. Subsequently, staged carotid stenting-open heart surgery experienced significantly fewer late hazard phase events in comparison to both staged endarterectomy-open heart surgery (adjusted hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.15 to 0.77; p=0.01) and combined endarterectomy-open heart surgery (adjusted HR: 0.35; 95% CI: 0.18 to 0.70; p=0.003).

Staged carotid artery stenting-open heart surgery and combined endarterectomy-open heart surgery are associated with similar risk of death, stroke or myocardial infarction in the short term, with both being better than staged endarterectomy-open heart surgery. However, the outcomes are significantly in favour of staged carotid artery stenting-open heart surgery after the first year.

“Our study shows that carotid stenting followed by open heart surgery should be the first line strategy for treating patients with severe carotid and coronary disease, if the three- to four-week wait between procedures is clinically acceptable,” said Shishehbor. “There has never been a randomised clinical trial to determine the best approach for these patients, but the evidence in this study may be enough to change practice.” He added, “As a result of this work, we are making changes to the way we approach patients with severe carotid and coronary artery disease at Cleveland Clinic. We are collaborating across disciplines to identify the lowest risk treatment option for each patient.”

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