Abstract 3229: Carotid Artery Stenting Prior to Coronary Bypass Surgery. Does the Available Information Support its Indication?
Even though the guidelines by the AHA/ACC state that carotid endarterectomy is probably recommended before or concomitant to CABG in patients with carotid stenosis, significant controversies to this recommendation still persist. The contribution of carotid disease as a direct cause of perioperative stroke has been difficult to prove In fact, a recent metaanlysis concluded that in asymptomatic patients, the available data do not support a clear benefit in stroke prevention by doing carotid endartherectomy. Carotid artery stenting (CAS) has been recently introduced as an alternative revascularization modality in high risk patients. The aim of the study was to define, based on the published information, if CAS is beneficial in this setting. Search of the MEDLINE and manual search of the literature from selected articles was performed. A total of 6 studies with 242 patients have been reported in the literature with CAS followed by a staged CABG. All studies were retrospective and single centers studies. The mean age was 67 years (40 – 89), 70% males. Asymptomatic carotid stenosis was present in 66% of patients. Most patients had a stable coronary condition. The mean time to CABG surgery was 40 days (7–157 days). The 30 days event rate after CABG, including all events during CAS were as followed: non-fatal stroke 5 patients (3.6%), mortality 18 patients (7.4%), and death and stroke, 23 patients (9.5%). Two patients (0.8%) die during the stent procedure, and only 3 patients (1.2%) developed stroke associated with CABG. The 30 days CABG mortality was 6.6%.
Conclusions: The low incidence of complication related to CAS and very low stroke rate associated with CABG surgery appears encouraging. However, the combined incidence of stroke and mortality is still significantly elevated, with the majority of the events occurring after CABG. These results might suggest that the presence of carotid stenosis is mainly a maker of a higher risk population and that solving the carotid problem might not change the overall outcome. Randomized evaluation of the role of carotid stenting in this setting is warranted.