Surgical Approach in Patients with Surgical Approach in Patients with Concomitant Carotid and Coronary Artery Concomitant Carotid and Coronary Artery Disease Disease Rashad MAHMUDOV Rashad MAHMUDOV Central Hospital of Central Hospital of Oilworkers, Baku- Oilworkers, Baku- Azerbaijan Azerbaijan
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Surgical Approach in Patients with Concomitant Carotid and Coronary Artery Disease Rashad MAHMUDOV Central Hospital of Oilworkers, Baku-Azerbaijan.
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Surgical Approach in Patients with Concomitant Surgical Approach in Patients with Concomitant
Carotid and Coronary Artery DiseaseCarotid and Coronary Artery Disease
StrokeStroke is the third leading cause of death is the third leading cause of death (795,000 people suffer a stroke, 164,000 (795,000 people suffer a stroke, 164,000 deaths/year) and leading cause of serious long-deaths/year) and leading cause of serious long-term disability in the U.S.term disability in the U.S.
AtherosclerosisAtherosclerosis accounts for up to one-third of accounts for up to one-third of all strokes.all strokes.
15-20% 15-20% of strokes is due to CAOD.of strokes is due to CAOD. 80% strokes 80% strokes occur in asymptomatic patients. occur in asymptomatic patients.
Patients referred for Patients referred for CABGCABG have a prevalence of have a prevalence of 17 - 22%17 - 22% for carotid stenosis for carotid stenosis > 50% > 50% and and 6 -12% for carotid stenosis 6 -12% for carotid stenosis > 80% (asymptomatic)> 80% (asymptomatic).. Conversely, significant CAD occurs Conversely, significant CAD occurs in nearly one third of pts with high-grade carotid stenosis who in nearly one third of pts with high-grade carotid stenosis who are being considered for CEA. are being considered for CEA.
The risk of The risk of perioperative strokeperioperative stroke after CABG: after CABG: 2% for carotid stenosis < 50% 2% for carotid stenosis < 50% 10% for carotid stenosis 50 – 80%10% for carotid stenosis 50 – 80% 19% for carotid stenosis greater than 80%.19% for carotid stenosis greater than 80%.
Plaque morphology: Plaque morphology: the presence of the presence of hypoechoichypoechoic or or echolucentecholucent plaque, plaque, plaque ulceration plaque ulceration etc.etc.
Prevalence of CS in CADPrevalence of CS in CAD
Tanimoto et al. Stroke, 2005.
Approach in combined CAD and CSApproach in combined CAD and CS
Fix the more Fix the more clinically active clinically active bed first in a staged bed first in a staged manner manner ????
Address the vascular bed with the Address the vascular bed with the tightest tightest stenosis stenosis ????
Revascularize the coronaries and the carotids Revascularize the coronaries and the carotids at at the same time the same time ????
Or…
Or…
Treatment options in concomitant CAD Treatment options in concomitant CAD and CSand CS
CEA ‘CEA ‘stagedstaged’ prior to CABG ’ prior to CABG
CEA ‘CEA ‘combinedcombined’ with CABG during the same ’ with CABG during the same anesthesia. anesthesia.
‘‘Reverse stagedReverse staged’, wherein CABG is performed ’, wherein CABG is performed prior to CEA (for emergency CABG situations prior to CEA (for emergency CABG situations only).only).
Study resultsStudy results Chiappini et alChiappini et al. 202 patients: The rate of perioperative stroke did not differ . 202 patients: The rate of perioperative stroke did not differ
significantly between the simultaneous CABG - CEA group and the sequential significantly between the simultaneous CABG - CEA group and the sequential operations group (operations group (6.4% vs 4.8%6.4% vs 4.8%). ).
Naylor Naylor et alet al.. 97 published studies (8,900 patients): the risk of stroke or death in 97 published studies (8,900 patients): the risk of stroke or death in CEA-CABG pts > than in pts undergoing staged procedures (CEA-CABG pts > than in pts undergoing staged procedures (8.7% vs. 6.1%8.7% vs. 6.1%). ).
Ricotta Ricotta et alet al.: increased incidence of stroke and death in patients undergoing .: increased incidence of stroke and death in patients undergoing the simultaneous CEA - CABG surgery approach.the simultaneous CEA - CABG surgery approach.
Hill et alHill et al.: combined rate of stroke and mortality of 13.0% with the joint .: combined rate of stroke and mortality of 13.0% with the joint procedure compared with 4.9% for CABG surgery alone.procedure compared with 4.9% for CABG surgery alone.
No study has shown the superiority of the combined procedure over the two-No study has shown the superiority of the combined procedure over the two-staged approach.staged approach.
High-risk subgroup with combinedHigh-risk subgroup with combinedcarotid and coronary artery diseasecarotid and coronary artery disease
Advantage of concomitant CEA-Advantage of concomitant CEA-CABGCABG
Lower costLower cost
One anesthesiaOne anesthesia
Shorter hospital stayShorter hospital stay
CEA continues to be CEA continues to be the gold standard the gold standard for treatment for for treatment for carotid stenosis. carotid stenosis. CAS has an expanding role for CAS has an expanding role for revascularization, particularly in high-risk patients.revascularization, particularly in high-risk patients.
Patients undergoing combined CABG-CEA enjoy Patients undergoing combined CABG-CEA enjoy excellent long-term excellent long-term freedom from strokefreedom from stroke, as well as, , as well as, good long-term survivalgood long-term survival. .
ConclusionsConclusions
The most recent guidelines suggest that CEA is The most recent guidelines suggest that CEA is recommended before or concomitant to CABG in recommended before or concomitant to CABG in patients with symptomatic carotid stenosis greater than patients with symptomatic carotid stenosis greater than 50% or asymptomatic carotid stenosis greater than 80%. 50% or asymptomatic carotid stenosis greater than 80%. If the procedures are to be staged, complication rates If the procedures are to be staged, complication rates are lower when carotid revascularization precedes are lower when carotid revascularization precedes CABG.CABG.
With the available observational studies, off-pump With the available observational studies, off-pump CABG may be considered in the setting of combined CABG may be considered in the setting of combined CEA-CABG when feasible.CEA-CABG when feasible.
ConclusionsConclusions
At last, At last,
the best management strategy for patients with the best management strategy for patients with concomitant surgical coronary artery disease in need of concomitant surgical coronary artery disease in need of CABG and significant carotid artery stenosis should be CABG and significant carotid artery stenosis should be based on individual patient characteristics, urgency of based on individual patient characteristics, urgency of revascularization, prioritization based on the revascularization, prioritization based on the symptomatic vascular territory, local expertise with an symptomatic vascular territory, local expertise with an integrated team approach by interventionalists, integrated team approach by interventionalists, neurologists and cardiothoracic surgeons, preferably in neurologists and cardiothoracic surgeons, preferably in high-volume centers.high-volume centers.
ConclusionsConclusions
Thank you Thank you for your attention !for your attention !