Is carotid angioplasty followed by cardiac surgery a safe and effective treatment for carotid artery stenosis?

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SYNOPSISBACKGROUNDThe optimum treatment strategy for patients with severe asymptomatic carotid artery stenosis who require cardiac surgery has not been established.OBJECTIVESTo assess the effectiveness and safety of prophylactic carotid angioplasty and stenting (CAS) prior to cardiac surgery in patients with severe asymptomatic carotid stenosis.DESIGNThis was a prospective, observational study of consecutive patients scheduled to undergo CAS and cardiac surgery between December 1997 and June 2005 at St Antonius Hospital, Nieuwegein, The Netherlands. All participants had an indication for cardiac surgery (i.e. coronary artery disease with myocardial ischemia, dissection or aneurysm of the ascending aorta or aortic arch, or symptomatic valve disease) and severe (>80%) carotid stenosis, and none had experienced an ipsilateral cerebrovascular event in the 4 months preceding enrollment. Patients were excluded if they had severe diffuse atherosclerosis, peripheral vascular disease that prevented femoral catheterization, severe renal impairment (serum creatinine ≥300 μmol/l), or a major neurological deficiency.INTERVENTIONAll patients received clopidogrel (loading dose 300 mg then 75 mg/day) and aspirin (loading dose 300 mg then 100 mg/day) for 3 days before femoral access CAS. The procedure was deemed successful if stenting achieved residual stenosis of 30% or less. Cardiac surgery (CABG surgery, reconstruction of the ascending aorta, or valve surgery) was scheduled for 14-30 days after CAS. Antiplatelet medication was discontinued 5 days before surgery.OUTCOME MEASURESThe primary outcome measure was combined incidence of death and stroke at 30 days after cardiac surgery. Secondary end points were myocardial infarction (MI) and the composite of MI, stroke, or death 30 days after surgery, and cumulative event rates at 5-years' follow-up.RESULTSA total of 356 patients (mean age 72.9 years) underwent CAS followed by cardiac surgery. The success rate for CAS was 97.7%. The mean duration between CAS and cardiac surgery was 22 days (range 1 day to 3 months). CABG surgery was performed in 319 patients (89.6%), of whom 23 underwent off-pump surgery. At 30 days after surgery, the combined stroke and death rate was 4.8% (n = 17) and the rate of MI, stroke, or death was 6.7% (n = 24); 7 patients (2.0%) suffered a nonfatal MI. During the 30-day follow-up period there were 13 deaths (3.7%), of which eight had a cardiac cause, one had a neurological cause, and four were caused by septicemia or multiorgan failure. The 5-year survival rate was 75.5%. Although patients aged 80 years or over had a significantly higher neurological and cardiac death rate than younger patients at 30 days (P = 0.03), the difference was not significant at 5 years. All cardiac and neurological deaths in the octogenarians occurred within 2 days of surgery.CONCLUSIONIn this cohort of patients, a strategy of CAS followed by cardiac surgery is associated with low short-term and long-term rates of stroke, MI, and death.

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