Author + information
- Mehdi H. Shishehbor, DO, MPH∗ (, )
- Sridhar Venkatachalam, MD and
- Eugene H. Blackstone, MD
- ↵∗Cleveland Clinic, Department of Cardiovascular Medicine, 9500 Euclid Avenue, J3-5, Cleveland, Ohio 44195
We do share the concerns raised by Dr. Naylor regarding the use of carotid revascularization for “low-risk” asymptomatic unilateral carotid disease in the open-heart surgery (OHS) population. Moreover, we have previously addressed this in our other publications (1,2). Of note, in the absence of a control group, we make no conclusion in our report (3) about who should undergo carotid revascularization in the face of imminent OHS. Rather, we present the risk involved with each of the 3 common approaches when a decision has already been made to treat severe disease in both territories. In general, it would be most appropriate to perform carotid revascularization in patients considered at “high risk” for stroke, such as those with symptomatic carotid disease, bilateral severe carotid stenosis, contralateral carotid occlusion or severe asymptomatic carotid stenosis accompanied by impaired cerebral perfusion reserve, transcranial Doppler microemboli, or magnetic resonance imaging evidence of complicated carotid plaque. An algorithmic approach to the management of concomitant severe carotid and coronary artery disease has been previously published by our group (1,2).
We disagree with Dr. Naylor’s comments regarding the editorial for the same reasons. We strongly believe that our analyses provide more clarity for clinicians amid the available conflicting evidence (4). We addressed many of the limitations of previous publications by accounting for interstage events, adjusting for multiple confounders, and examining the early and late risk associated with treating both territories. Clearly, once a decision has been made to treat the carotid disease in patients undergoing OHS, the staged approach of carotid artery stenting and OHS is superior to the other 2 approaches. In the absence of level 1 evidence, the role of carotid revascularization in this population will remain debatable. In the meantime, we anticipate that real-world practice will change in favor of careful patient selection (on the basis of “high-risk” features as described previously) and treated according to the best available evidence.
Please note: The REDCap project is supported by the National Center for Research Resources of the National Institutes of Health. Dr. Shishehbor is a speaker and consultant for Abbott Vascular, Medtronic, and GORE, but has waived all compensations for this work. Dr. Blackstone is supported in part by the Kenneth Gee and Paula Shaw, PhD, Chair in Heart Research. Dr. Venkatachalam has reported that he has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Venkatachalam S.,
- Gray B.H.,
- Mukherjee D.,
- Shishehbor M.H.
- Shishehbor M.H.,
- Venkatachalam S.,
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- et al.