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Myocardial infarction (MI) remains the most common cause of mortality in the world, while stroke is the second leading cause of death and most common cause of disability. Atherosclerosis is a diffuse process that affects multiple vascular beds. Severe carotid, vertebral or subclavian stenosis is found in 16.6% of patients with triple vessel coronary artery disease (CAD), whereas multi-vessel coronary disease and significant carotid stenosis coexists in 2.8–22% of patients undergoing coronary artery bypass grafting (CABG). With an increase in elderly patients incidence of concomitant carotid and coronary artery disease will continue to increase. Concomitant severe coronary and carotid artery disease increase the risk of death, stroke, or myocardial infarction. The management of concurrent severe carotid and coronary artery disease is still controversial. Trials like Sapphire, EVA, Space, ICSS, CREST, and Sharp showed non-inferiority of carotid artery stenting (CAS) with respect to carotid endarterectomy (CEA). But still debate is on which strategy is better. Carotid artery stenting (CAS) using cerebral protection devices is rapidly evolving as an alternative to carotid endarterectomy, mainly for patients with severe carotid artery stenosis who are at high surgical risk, such as patients with coronary artery disease. We planned to study whether carotid artery stenting is safe and effective in patients with co-existing coronary artery disease.
Carotid artery stenting has been accepted as a potential alternative to carotid endarterectomy inpatients with significant carotid artery stenosis. The objective of this study was to evaluate the feasibility, safety and short-term outcome of Carotid artery stenting in patients with coexisting symptomatic coronary artery disease.
Medical records of patients who underwent CAS at Fortis Escorts Heart Institute and Research Center, since January 2015 were reviewed. We also maintained a prospective registry of all patients undergoing CAS at our hospital. Patients with CAS were selected for study if they satisfied following inclusion criteria: 1) Combined carotid and coronary artery disease; 2) Patients at high risk of CEA and having indication for CAS, (restenosis after CEA, contralateral carotid artery occlusion or laryngeal nerve palsy, bilateral carotid artery stenosis, previous radiation therapy or surgery on the neck, neck immobility, tracheostomy or tracheostoma, severe intracranial lesion, lesion inaccessible by surgery, advanced CAD example acute coronary syndrome, three vessels disease or left main disease, heart failure, severe aortic stenosis, left ventricular ejection < 30%, renal failure, planned CABG or valve replacement, chronic obstructive pulmonary disease, cardiac and pulmonary disease, planned peripheral vascular surgery, myocardial infarction within 6 weeks of the procedure, age older than 80 years)
4) Adults>18 years
5) Carotid angiography showed carotid stenosis > 50% if symptomatic and >70% if asymptomatic.
1) Stroke / TIA / Amaurosis fugax within the past 14 days
2) Severely disabled as a result of stroke or dementia
3) Complete occlusion of carotid artery
4) Severe calcification, tortuosity of carotid artery
5) Intracranial tumor or cerebral venous malformation.
The degree of stenosis was measured with duplex ultrasound scanning and arch aortography, according to the North American Asymptomatic Carotid Endarterectomy Trial (NASCET) method. Statististical analysis was done using Mann Whitney test.
All patients were seen by neurologist within 24 hrs after CAS, after 1 week and after 30 days. Patients were instructed to inform the coordinator (research nurse) or general practitioner if any symptoms possibly related to an ischemic event occurred after hospital discharge. Medical and nursing records were reviewed to determine nature and time of complications in the hospital and 30 days after CAS.
44 (77.2%) patients were male. The mean age of patients was 65 ± 8 years. 40 (71.9%) patients were neurologically asymptomatic. Symptomatic patient had predominant symptoms of chest pain, dyspnea, syncope/presyncope, dizziness, blurring of vision, paresis/paralysis. 47.4% patients had unilateral and 52.5% patients had bilateral carotid artery disease. Amongst all patients 59.6% had TVD, 17.5% had DVD, 14% had SVD & 8.8% patients had non-critical CAD. Among them 38.6% patients underwent PCI, 33.3% patients underwent surgery, 17.5% patients underwent both PCI and surgery and 10.6% patients were managed medically. Only 1 patient died after the procedure.
Complications after CAS was seen in 10 patients: 1 patient had a stroke, 1 had shock, 6 patients had acute renal failure, 1 patient had infection and 1 patient had arrhythmia (Table2). One patient died. After discharge from the hospital, we followed all patients. Of all patients 4 had a myocardial infarction, 1 patient had stroke (infarct) and 3 patients had worsening renal failure (Table3). There was no significant difference between in-hospital complication and complication at one month after CAS.
This is small registry with retrospective date to analyse. No randomized trial comparing different treatment strategies for concomitant carotid and coronary artery disease management has been conducted till date so thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-center, studies are required before this can become widely applied.
We showed that for CAS EPD should be used to reduce complications. No significant difference between complications during hospitalization and within 30 days of CAS was seen. Severe combined carotid and coronary artery disease can be managed safely by hybrid approach.