1. Rashad MAHMUDOV Central Hospital of Oilworkers, Baku-Azerbaijan
Surgical Approach in Patients with Concomitant Carotid and Coronary Artery Disease
Rashad MAHMUDOV Central Hospital of Oilworkers, Baku-Azerbaijan

2. Carotid artery disease: Overview
Stroke is the third leading cause of death (795,000 people suffer a stroke, 164,000 deaths/year) and leading cause of serious long-term disability in the U.S.
Atherosclerosis accounts for up to one-third of all strokes.
15-20% of strokes is due to CAOD.
80% strokes occur in asymptomatic patients.

3. Cause of stroke and TIA Embolus Thrombosis Carotid atheroma Cardiac
Atrial fibrillation
Mural thrombus
Patent foramen ovale
Thrombosis
Abnormality of vessels
Atherosclerosis
Autiimmune disease
Vasculitis
Wall dissection
Abnormal clotting
Polycythemia
Thrombocythemia
Hyperviscosity
Clotting disorders
Inherited
acquired
Migraine?
Although only 40% to 50% of strokes after CABG are ipsilateral to an existing carotid lesion, carotid revascularization is one of the few available options to reduce the excessive stroke and death rates in patients with combined disease.
Prophylactic carotid revascularisation would prevent % of perioperative stroke in asymptomatic patients.

4. Extracranial and Intracranial circulation
The proximal internal carotid artery and the carotid bifurcation are most frequently involved

5. Risk factors for carotid stenosis
Age
Sex: man > woman
Diabetes mellitus
Hypertension
Smoking, alcohol
Dyslipidemia

6. Symptoms of carotid stenosis
Temporary monocular blindness (embolization to the ophthalmic artery).
Transient Ischemic Attack (TIA).
Stroke (stroke risk symptomatic >> asymptomatic) % stenosis 2 yrs risk = 26%.
A carotid bruit should be heard in the majority of patients with carotid stenosis > 75%.

7. Evaluation of carotid artery stenosis
Carotid duplex ultrasonography
Transcranial Doppler
MR angiography (MRA)
CT angiography (CTA)
Carotid angiography - the gold standard (1.3% neurological complication rate).

8. Carotid Artery Stenosis
Carotid angiography

9. Treatment options Best treatment --- ??? Carotid artery stenting (CAS)
Medical therapy (BMT)
Aspirin
Statin
Hypertension
Diabetes
Dyslipidemia
Carotid artery stenting (CAS)
Carotid endarterectomy (CEA)

10. Concomitant Coronary and Carotid Artery Disease

11. Concomitant Coronary and Carotid Artery Disease
Patients referred for CABG have a prevalence of % for carotid stenosis > 50% and 6 -12% for carotid stenosis > 80% (asymptomatic). Conversely, significant CAD occurs in nearly one third of pts with high-grade carotid stenosis who are being considered for CEA.
The risk of perioperative stroke after CABG:
2% for carotid stenosis < 50%
10% for carotid stenosis 50 – 80%
19% for carotid stenosis greater than 80%.
Plaque morphology: the presence of hypoechoic or echolucent plaque, plaque ulceration etc.
The current 2004 American College of Cardiology/American Heart Association guidelines for CABG have given a Class IIa indication for routine carotid screening in those with left main disease, smoking, age greater than 65 years, and peripheral vascular disease.

12. Prevalence of CS in CAD
Tanimoto et al. Stroke, 2005.

13. Approach in combined CAD and CS
Fix the more clinically active bed first in a staged manner ??
Address the vascular bed with the tightest stenosis ??
Revascularize the coronaries and the carotids at the same time ??
Or…
Or…
Careful patient selection is paramount and this traditionally has relied upon symptom status and disease severity involving the carotid and coronary beds.

14. Treatment options in concomitant CAD and CS
CEA ‘staged’ prior to CABG
CEA ‘combined’ with CABG during the same anesthesia.
‘Reverse staged’, wherein CABG is performed prior to CEA (for emergency CABG situations only).

15. Study results
Chiappini et al. 202 patients: The rate of perioperative stroke did not differ significantly between the simultaneous CABG - CEA group and the sequential operations group (6.4% vs 4.8%).
Naylor et al. 97 published studies (8,900 patients): the risk of stroke or death in CEA-CABG pts > than in pts undergoing staged procedures (8.7% vs. 6.1%).
Ricotta et al.: increased incidence of stroke and death in patients undergoing the simultaneous CEA - CABG surgery approach.
Hill et al.: combined rate of stroke and mortality of 13.0% with the joint procedure compared with 4.9% for CABG surgery alone.
No study has shown the superiority of the combined procedure over the two-staged approach.
A systematic review of 97 studies between 1972 and 2002 by Naylor et al. [47] concluded no significant overall difference in 30-day death, MI, or stroke risk for staged and combined procedures, with the risk being 10–12%. Further support for these findings comes from a more recent and large study by Gopaldas et al. [48] using the National Inpatient Sample (NIS) database 1998–2007 with patients. Mortality and neurological complications were statistically similar for both the staged and combined procedures in this study; however, data on interval deaths in the staged group were not included.

18. Systematic reviews and meta-analyses that have assessed perioperative outcomes of staged and simultaneous CEA and CABG demonstrate no significant differences in outcomes between the two strategies, albeit staged procedures have generally been associated with lower stroke and death rates than simultaneous ones.

19. In the management of carotid stenosis, carotid artery stenting (CAS) with embolic protection is a less invasive, safe, and durable alternative to CEA in patients considered high risk for CEA, such as those with severe CAD in need of open heart surgery (OHS). CAS remains an important alternative option in patients deemed to be at high risk for CEA from the cardiac standpoint.
Asymptomatic 80–99% carotid stenosis in the setting of coronary artery bypass surgery may be managed conservatively in the absence of high-risk factors.
Carotid artery stenting, if anatomically feasible, should be viewed as the procedure of choice in asymptomatic patients with severe coronary artery disease given the increased risk of myocardial infarction associated with carotid endarterectomy.

20. High-risk subgroup with combined carotid and coronary artery disease
Neurological symptoms (stroke / TIA).
Bilateral carotid stenosis 80–99%.
Unilateral 50–99% carotid stenosis with contralateral occlusion.
Asymptomatic 80–99% carotid stenosis with impaired cerebral perfusion reserve.

21. Advantage of concomitant CEA-CABG
Lower cost
One anesthesia
Shorter hospital stay

22. In patients with neurologic symptoms, carotid revascularization should be performed prior to or in conjunction with coronary artery bypass surgery.

24. Conclusions
CEA continues to be the gold standard for treatment for carotid stenosis. CAS has an expanding role for revascularization, particularly in high-risk patients.
Patients undergoing combined CABG-CEA enjoy excellent long-term freedom from stroke, as well as, good long-term survival.

25. Conclusions
The most recent guidelines suggest that CEA is recommended before or concomitant to CABG in patients with symptomatic carotid stenosis greater than 50% or asymptomatic carotid stenosis greater than 80%. If the procedures are to be staged, complication rates are lower when carotid revascularization precedes CABG.
With the available observational studies, off-pump CABG may be considered in the setting of combined CEA-CABG when feasible.

26. Conclusions
At last,
the best management strategy for patients with concomitant surgical coronary artery disease in need of CABG and significant carotid artery stenosis should be based on individual patient characteristics, urgency of revascularization, prioritization based on the symptomatic vascular territory, local expertise with an integrated team approach by interventionalists, neurologists and cardiothoracic surgeons, preferably in high-volume centers.

27. Thank you for your attention !