Simultaneous or staged carotid artery stenting and coronary artery bypass grafting as the revascularization strategy for severe, concurrent carotid and coronary disease in TARGET-CAS study population

Abstract

Purpose: To evaluate safety and feasibility of two revascularization methods for patients with severe/symptomatic carotid and coronary artery disease (CAD): simultaneous, hybrid carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) and two staged CAS and CABG. Methods and results: From 2009 to 2012, 55 patients (age 69.6±6.3y, 74% men; see table) from the TARGET-CAS (Carotid Artery Stenting With Patient- and Lesion-Tailored Selection of the Neuroprotection System and Stent Type) registry had a revascularization by CAS combined with CABG. Those with unstable angina/NSTEMI underwent hybrid CAS + CABG - CABG was done immediately after CAS. Others with severe, but stable CAD had two sequential procedures: CAS in first stage and CABG ∼5 weeks later: CAS-then-CABG. In CAS+CABG group CAS was done on acetylsalicylic acid and unfractioned heparin only and loading dose of clopidogrel (300mg) was given in 6th-10th postoperative hour, if major surgical bleedings were excluded. CAS-then-CABG patients had dual antiplatelet therapy for a month after CAS, clopidogrel was withdrawn 5-7 days before CABG. All CAS procedures in both groups were successful. Among hybrid CAS+CABG patients one myocardial infarct (successfully treated by percutaneous right coronary artery angioplasty) and one death as a result of multi-organ failure occurred (6.9%) in the early post-operative period. In CAS-then-CABG group no major inhospital and 30-day cardiac complications were noted (p=0.49). There was no strokes in both groups. (Table presented) Conclusion: Our results suggest that simultaneous or staged CAS before CABG is feasible for patients with severe/symptomatic carotid stenosis and CAD. It seems to be an effective method to prevent perioperative stroke, coronary unstable patients appear to have higher risk of perioperative death/MI.