1. VASIL VELCHEV ST. ANNA HOSPITAL, SOFIA

2. Conflict of interest:

3. Last case from St.Anna CAS before CABG  72 y.o. male  Hypertension, NIDDM  Present to CCU with decubital angina and shortness of breadth  ECG – unspecific repol abnormalities  Echo – EF- 42%, AR – 2, MR -1, diastolic dysfunction  Tn ++  No history of TIA/stroke  Bilateral ICA stenosis- Doppler

4. Cath 18 h later SYNTAX SCORE 36

5. Carotid angio confirms Doppler findings RCCALCCA

6. ??????????  Shall we treat the carotids?  What test will help the decision?  Timing : staged or simultaneous?  Treat one(which one?) or both?  CAS or CEA or ?  Protocols for CAS – antiagregants Tx?

7. 16. Recommendations for Carotid Artery Evaluation and Revascularization Before Cardiac Surgery Class IIa  Carotid duplex ultrasound screening is reasonable before elective coronary artery bypass graft (CABG) surgery in patients older than 65 years of age and in those with left main coronary stenosis, PAD, a history of cigarette smoking, a history of stroke or TIA, or carotid bruit. (Level of Evidence: C)  Carotid revascularization by CEA or CAS with embolic protection before or concurrent with myocardial revascularization surgery is reasonable in patients with greater than 80% carotid stenosis who have experienced ipsilateral retinal or hemispheric cerebral ischemic symptoms within 6 months. (Level of Evidence: C) Class IIb  In patients with asymptomatic carotid stenosis, even if severe, the safety and efficacy of carotid revascularization before or concurrent with myocardial revascularization are not well established. (Level of Evidence: C) 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary

8. Carotid stenosis revascularization and preoperative risk of stroke – what everybody seems to agree on  Asymptomatic unilateral – no benefit  Asymptomatic bilateral – debatable  Symptomatic – should be revascularized  Most strokes in patients without carotid stenosis ( most often in posterior brain circulation) Naylor AR J Cardiovasc Surg 2009 Mahmoudi Stroke 2011

9. What is asymptomatic severe stenosis? Silent embolic infarcts on computed tomography brain scans and risk of ipsilateral hemispheric events in patients with asymptomatic internal carotid artery stenosis. *  2 fold increase of stroke on FU CONCLUSION: The presence of silent embolic infarcts can identify a high-risk group for ipsilateral hemispheric neurologic events and stroke and may prove useful in the management of patients with moderate asymptomatic carotid stenosis. - CT of our patient revealed silent ischemic cortical lesions on the right hemisphere * Kakkos SK,et al. Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group J Vasc Surg. 2009

10. No strokes reported while waiting for CABG – mean 32 days !! CAS and wait before CABG – high rate of AE Early CAS experience ? No report on operator experience?

11. Date of download: 5/13/2013 Copyright © The American College of Cardiology. All rights reserved. From: Simultaneous Hybrid Revascularization by Carotid Stenting and Coronary Artery Bypass Grafting: The SHARP Study Versaci et al. > 150 CAS per operator required !!!! J Am Coll Cardiol Intv. 2009;2(5):393-401. doi:10.1016/j.jcin.2009.02.010 Actuarial Event-Free Survival at 12 Months Kaplan-Meier event-free survival in patients that underwent simultaneous hybrid revascularization by carotid artery stenting and coronary artery bypass graft surgery. The 12-month cumulative incidence of disabling stroke, acute myocardial infarction, or death was 7%. Three patients died between the 31st day and 12 months after intervention. Figure Legend: 101 pts 55% bilateral disease 85% asymptomatic Same day CASS SUCCESS – 98% The 30-day cumulative incidence of disabling stroke or death was 4%:

12. Why not CEA?  Higher risk of periprocedural MI……. Can influence the results of CABG and long term mortality and…

13. Consensus Guidelines 2011

14. Kaplan-Meier survival curves after randomized carotid revascularization in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Blackshear J L et al. Circulation 2011;123:2571-2578 Copyright © American Heart Association

15. Why not CEA?  Higher risk of periprocedural MI……. Can influence the results of CABG and long term mortality  Every hospital shall rely on local experience (CAS vs.CEA) for achieving best outcomes

16. Date of download: 5/14/2013 Copyright © The American College of Cardiology. All rights reserved. From: Influence of Site and Operator Characteristics on Carotid Artery Stent Outcomes: Analysis of the CAPTURE 2 (Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events) Clinical Study J Am Coll Cardiol Intv. 2011;4(2):235-246. doi:10.1016/j.jcin.2010.10.009 Patient DS by Specialty (A) Death and stroke (DS) rate by number of patients/physician for interventional cardiologists (dotted horizontal line indicates American Heart Association guideline of 3% event rate for asymptomatic patients). (B) Linear regression of DS rate by number of patients for interventional cardiologists. (C) The DS rate by number of patients for vascular surgeons (dotted horizontal line indicates American Heart Association guideline of 3% event rate for asymptomatic patients). (D) Linear regression of DS rate by number of patients for vascular surgeons. Figure Legend:

17. Copyright ©2008 American Heart Association Theiss, W. et al. Stroke 2008;39:2325-2330 Pro-CAS registry –predictors of complications

18. Same day CAS on RICA and CABG+AVR on heparin and aspirin(SHARP protocol)

19. Peculiarities of same day CAS+CABG  Use your usual technique  No clopodogrel  Preload Aspirin + statin  Heparin ACT >200 until transferred to OR  Replace the long sheet with short one and suture to the skin at the end of procedure

20. Take home message  Carotid Revascularization should be part of heart team decision  CAS or CEA based on results of local operators  Simultaneous or staged procedure – urgency of coronary revascularization is decisive but excess of coronary event is observed in a waiting period

21. Thank u for your attention!