A retrospective analysis comparing different approaches to carotid revascularization in patients with severe carotid artery stenosis who required open heart surgery for coronary artery disease found that outcomes significantly favored staged carotid artery stenting followed by open heart surgery, and that both combined carotid endarterectomy with open heart surgery and the staged carotid artery stenting followed by open heart surgery were superior to staged carotid endarterectomy followed by open heart surgery in terms of outcomes. The results were published July 31 in the Journal of the American College of Cardiology.

The study evaluated the outcomes of 350 patients with severe carotid artery stenosis who underwent one of the three approaches to carotid revascularization within 90 days prior to planned open heart surgery at Cleveland Clinic: staged carotid endarterectomy followed by open heart surgery; combined carotid endarterectomy with open heart surgery; and staged carotid artery stenting followed by open heart surgery.

At one year of follow up, the study found that staged carotid artery stenting followed by open heart surgery resulted in a lower risk of the composite endpoint of all-cause death, stroke, and myocardial infarction (MI), than staged carotid endarterectomy-open heart surgery and a similar risk compared with combined carotid endarterectomy-open heart surgery. Results at follow-up beyond one year showed that patients who underwent staged carotid artery stenting-open heart surgery had a significantly lower risk of the composite outcomes compared with the patients who underwent the combined carotid endarterectomy-open heart surgery procedure (adjusted hazard ratio [HR]: 0.35; 95 percent confidence interval [CI]: 0.18 to 0.70; p = 0.003) and staged carotid endarterectomy-open heart surgery (adjusted HR: 0.33; 95 percent CI: 0.15 to 0.77; p = 0.01).

The authors conclude that staged carotid artery stenting-open heart surgery and combined carotid endarterectomy-open heart surgery are associated with a similar risk of death, stroke, or MI in the short term, with both being better than staged carotid endarterectomy-open heart surgery, and that outcomes after the first year significantly favor staged carotid artery stenting-open heart surgery.

“Staged carotid endarterectomy followed by open heart surgery poses substantial risk of inter-stage MI in the open heart surgery population and hence should be avoided if possible,” the authors note. In choosing between staged carotid artery stenting-open heart surgery and combined carotid endarterectomy-open heart surgery, the increased risk of interstage MI with the former and perioperative stroke with the latter are important considerations despite similar risks for the early composite end point,” they add.

In an accompanying editorial, Ehtisham Mahmud, MD, FACC, Ryan Reeves, MD, of the Division of Cardiovascular Medicine and Sulpizio Cardiovascular Center, University of California, San Diego, note that study “provides clarity in the management of patients with carotid and coronary disease requiring open heart surgery.” In patients for whom it is not safe to wait three to four weeks for open heart surgery after carotid endarterectomy, combined carotid endarterectomy-open heart surgery is the optimal revascularization strategy, for those who can wait, staged carotid artery stenting-open heart surgery provides superior short- and long-term outcomes, they add.

Keywords: Coronary Artery Disease, Myocardial Infarction, Stroke, Follow-Up Studies, Endarterectomy, Carotid, Carotid Artery Diseases, Confidence Intervals, Cardiac Surgical Procedures, Carotid Stenosis, United States