Carotid Disease and CABG: What is the best Treatment

Carotid Disease and CABG: What is the best Treatment Dual Antiplatelets Luis A Guzman, MD, FACC, FSCAI Professor of Medicine Director, Cardiovascular Cath Lab Virginia Commonwealth University

Stroke during CABG. Main Causes Incidence 2% Low cardiac output Arrhythmias Oxygenation system Perfusion system Aortic arch Atherosclerosis Carotid stenosis

Stroke during CABG. Main Causes Incidence 2% Low cardiac output Arrhythmias Oxygenation system Perfusion system Aortic arch Atherosclerosis Carotid stenosis

Stroke Rate in Carotid Stenosis and CABG 18 12 Carotid (-) Carotid (+) 14.9 18 12 Carotid (-) Carotid >5 Bilateral Occlusion 11.2 6 6 5.2 1.9 1.8 3 Stroke Stroke Brener et al. J Th Surg 1984 Naylor et al. Eur J Vasc Endovasc Surg. 23;26:23-41

Carotid Revascularization prior to CABG The guidelines by the AHA/ACC states that carotid endartherectomy is probably recommended before CABG or concomitant to CABG in patients with a symptomatic carotid stenosis or in asymptomatic patients with a unilateral or bilateral internal carotid stenosis of 8% or more (Indication IIa; Level of Evidence: C) AHA/ACC Guidelines. Circulation 26;113:1474

Carotid Revascularization prior to CABG Rational Strokes are associated with carotid stenosis CEA or CAS are indicated to decrease the incidence of stroke that would otherwise happen if carotid revascularization was not performed Where is the evidence?

Carotid Revascularization prior to CABG Rational Not a single randomized study exist today evaluating the hypothesis of stroke prevention for carotid revascularization prior to or during CABG In the USA there are +25, combined procedures/year

Carotid Revascularization prior to CABG Concerns and Flawed Many reports do not discriminate between symptomatic and asymptomatic Many report do not differentiate between unilateral, bilateral or occlusions Overestimation of event. Publication bias

Carotid Revascularization prior to CABG Concerns Among patients with stroke post CABG 5% had no Carotid disease 6% had disease in the opposite carotid Most strokes are in those with prior stroke but no carotid stenosis Overall, only 2% of the strokes were related to the ipsilateral carotid stenosis DeAgostino RS et al. Ann Thor Surgery 1996;82:1714

Carotid Revascularization prior to CABG Symptomatic Carotid Stenosis This is a different patient The associated CAD will change the risk profile but carotid revascularization should be performed first In very unusual situation with associated Unstable CAD, combined surgery could be considered

CEA and CABG Metaanalysis of 97 publications 16 12 8 4 5.4 Combined Staged 3.7 9.8 7.8 8,972 Asymptomatic Patients Stroke Death/Stroke Naylor et al. Eur J Vasc Endovasc Surg. 23;25:38-9

CEA and CABG Metaanalysis of 97 publications <1% of pts 16 12 Combined Staged 9.8 18 12 Carotid (-) Carotid >5 Bilateral Occlusion 11.2 8 4 5.4 3.7 7.8 6 1.8 3 5.2 Stroke Death/Stroke Stroke Naylor et al. Eur J Vasc Endovasc Surg. 23;25:38-9

Stroke rate after CABG in Asymptomatic Severe Carotid Stenosis A Metaanalysis 2,531 pts All Symptomatic/Asymptomatic Patients Asymptomatic Patients 1 9,1 1 8 6 7,4 7,4 8 6 6,5 5,8 4 4 3,8 2 2 2 > 5% > 7% > 8% > 5% > 7% Bilateral CEA/CABG Naylor AR et al. Eur J Vasc Endovasc 211,41:67-24

Stroke rate after CABG in Asymptomatic Bilateral Severe Carotid Stenosis with Combined Unilateral CEA: A Metaanalysis 22 pts 8 7 Contralateral Stroke 6,7 6 5 4 3 2 1 3,8 3,8 5,2 Bilat 5-99 Occlusion + >5% No CEA Bilat No CEA Occlusion Naylor AR et al. Eur J Vasc Endovasc 211,41:67-24

Carotid Stenting prior to CABG Possible Advantages of Stent over CEA No general anesthesia Less Invasive Antiplatelets therapy can be maintained Stroke rate? Mortality?

Carotid Stenting prior to CABG Systematic Analysis of 277 pts Major Events after Stent at Discharge 1 8 4 Deaths 2 Fatal strokes 2 Cardiac deaths 6 4 2 2.9 1.1 1.4 4.7 < Stroke > Stroke Death Death/Str

Carotid Stenting prior to CABG Systematic Analysis of 277 pts Major Events after Stent waiting for CABG 6 4 2 2.2 2.2 < Stroke > Stroke Death Death/Str All 6 patients died due to a cardiac causes

Carotid Stenting prior to CABG Systematic Analysis of 277 pts 1 8 Major Events 3 days after CABG 6 4 4.2 5.7 2 1.5 Stroke Death Death/Str

15 Carotid Stenting prior 21 Deaths to CABG 4 Fatal strokes 17 Cardiac deaths 2 post stent Systematic Analysis of 277 pts Overall Major Events 3 days after CABG 6 waiting for CABG 9 post CABG 12 11.6 9 6 7.6 8.7 3 2.9 2.5 < Stroke > Stroke Death Death/>Str Death/Str

Simultaneous versus Delay CEA + CABG Randomized Study of Asymptomatic Patients with Unilateral Severe Carotid Stenosis: 9 Days Outcomes 1 8 6 4 2 Simultaneous (n:94) Delay (n:91) 1 1,1 All Strokes occurred after CABG, before CEA Patients was aortic disease were excluded Overall Stroke: 4.5% D/Stroke: 4.9% Death Stroke D/Stroke 7 1 8,8 Illuminati G et al. J Vasc Surgery 211,54:993-9

Endovascular, Surgical or Hybrid for Patients with Combined Carotid and CAD The FRIENDS trail (n:659) 1 8 Predictors of Primary end point Endovascular: OR=.369; 95%CI=.168-.813, p=.1 Hybrid: OR=3.98; 95%CI=1.359-7.6, p=.7 8,6 6 4 2 4,25 4,8 2,4 All Surgery Endovascular Hybrid Ribichini F et al. Eurointervention 21,3:328-35

Endovascular, Surgical Combined or Surgical Staged for Patients with Associated Carotid and CAD. The CCF Registry (n:35) 3 Days Results 35 3 25 2 15 1 5 1 31 P=.1 P=.1 Stent (n:11) 24 Most MI occurred while waiting for CABG in Staged group CAS delay to CABG mean 47 days CEA delay to CABG, mean 14 days P=.75 1 5 7 Combined (n:195) Staged (n:45) 6 D/MI/Stroke Death Stroke MI 7 2 P=.11 2 1 3 Shishehbor et al. JACC 213;62:1948-56

Endovascular, Surgical Combined or Surgical Staged for Patients with Associated Carotid and CAD. The CCF Registry (n:35) 1 Year Results 45 4 35 3 4 P=.1 Combined (n:195) Staged (n:45) Stent (n:11) P=.1 25 2 15 1 5 17 16 P=.84 16 12 13 24 P=.6 8,7 6,7 D/MI/Stroke Death Stroke MI 1,8 1 3,6 Shishehbor et al. JACC 213;62:1948-56

Combined Carotid Endartherectomy and Off Pump CABG?

Carotid Revascularization prior to CABG High Risk Patients: Screening LMT Associated PAD Smoker 65 years Prior CVA/TIA Bilateral disease Chronic occlusion AHA/ACC Guidelines. Circulation 26;113:1474

Do We Need Carotid Screening in Asymptomatic Patients? Lin J et. J Vasc Surgery 216: 63:71-14

Outcomes post CABG According to Carotid Screening 8 6 4 Carotid Screening (n:36) No Screening (n:1417) P=.27 4,3 P=.7 2,9 2,9 2,6 2 Death Stroke

Randomized Studies of CEA vs Medical management in CABG Patients with Asymptomatic stenosis. Does not include Stent arm. CABACS Trial Asymptomatic High Grade Carotid Stenosis CABG CABG + CEA N CABG + Stent Arm Int J Stroke, 7 (212), pp. 354 36

Combined CAD and Carotid Stenosis Symptomatic Carotid Asymptomatic Carotid Asymptomatic CAD Symptomatic CAD Prior Stroke Severe Bilateral Dz Contralateral Occlusion Unilateral Stenosis No prior Strokes Carotid Revascularization CEA vs CAS CAD Treatment Combined Carotid (1 st ) and CABG CAS vs CEA According to anatomy No data (?) Higher risk group CABG alone probably as good as Combined CABG + Medical Management Unless prior stroke Carotid Screening is not required

Combined CAD and Carotid Stenosis Symptomatic Carotid Asymptomatic Carotid Asymptomatic CAD Symptomatic CAD Prior Stroke Severe Bilateral Dz Contralateral Occlusion Unilateral Stenosis No prior Strokes Carotid Revascularization CEA vs CAS CAD Treatment Combined Carotid (1 st ) and CABG CAS vs CEA According to anatomy No data (?) Higher risk group CABG alone probably as good as Combined Role of Carotid Stent? Role of Coronary stent? CABG + Medical Management Unless prior stroke Carotid Screening is not required