A Direct Comparison of Early and Late Outcomes With Three Approaches to Carotid Revascularization and Open Heart Surgery

Study Questions:

What are the risk-adjusted outcomes of three approaches to carotid revascularization in the open heart surgery (OHS) population?

Methods:

From 1997-2009, 350 patients underwent carotid revascularization within 90 days prior to OHS at a tertiary center: 45 staged carotid endarterectomy (CEA)-OHS, 195 combined CEA-OHS, and 110 staged carotid artery stenting (CAS)-OHS. The primary composite endpoint was all-cause death, stroke, and myocardial infarction (MI). Staged CAS-OHS patients had higher prevalence of prior stroke (p = 0.03) and underwent more complex OHS. Therefore, propensity score adjusted multiphase hazard function models with modulated renewal to account for staging and competing risks were used.

Results:

Using propensity analysis, staged CAS-OHS and combined CEA-OHS had similar early hazard phase composite outcomes, whereas staged CEA-OHS incurred the highest risk driven by interstage MI. Subsequently, staged CAS-OHS experienced significantly fewer late hazard phase events in comparison to both staged CEA-OHS (adjusted hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.15-0.77; p = 0.01) and combined CEA-OHS (adjusted HR, 0.35; 95% CI, 0.18-0.70; p = 0.003).

Conclusions:

The authors concluded that staged CAS-OHS and combined CEA-OHS are associated with similar risk of death, stroke, or MI in the short term, with both being better than staged CEA-OHS.

Perspective:

This study suggests that among the three common approaches in the management of concomitant severe carotid and coronary artery disease, there were no significant differences in composite outcomes between staged CAS-OHS and combined CEA-OHS in the short term. However, beyond 12 months, the staged CAS-OHS option appeared to be a better choice. In choosing between staged CAS-OHS and combined CEA-OHS, clinicians need to take into account the increased risk of interstage MI with staged CAS-OHS and perioperative stroke with combined CEA-OHS despite similar risks for the early composite endpoint. Additional prospective studies are indicated to define optimal revascularization strategies in patients with concomitant carotid and coronary disease, including an arm with optimal medical therapy and no carotid intervention.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Vascular Medicine

Keywords: Risk, Stroke, Myocardial Infarction, Coronary Artery Disease, Propensity Score, Endarterectomy, Carotid, Stents, Prevalence, Incidence, Proportional Hazards Models, Confidence Intervals, Carotid Stenosis, Cardiac Surgical Procedures, Coronary Artery Bypass


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