Simultaneous and staged surgical treatment of carotid artery stenosis in patients with coronary artery disease: remote results

Резюме

Background. The systemic nature of vascular lesions in atherosclerosis leads in 2.4-14% of patients to hemodynamically significant combined lesions of the coronary and carotid basins. For these patients, recommendations on surgical treatment remain uncertain, with the discussions concerning advantages of various surgical techniques still going on.

Objective. This study was aimed at assessing the results of simultaneous and staged treatment of patients with combined lesions of brachiocephalic arteries and coronary artery disease.

Patients and methods. Patients were recruited into the study retrospectively according to the “continuous observation”. Between September 2012 and March 2022, we performed surgical treatment of a total of 5,340 patients with coronary artery disease. Significant concomitant lesions of coronary arteries and brachiocephalic arteries were diagnosed in 852 (16%) patients. The mean age of patients amounted to 65.9±14.2 years (form 38 to 84 years). Staged surgical treatment (with the first stage consisting in carotid endarterectomy and the second stage being coronary artery bypass grafting) was performed in 693 (81.3%) patients and simultaneous treatment in 159 (18.7%) patients. Risk stratification according to the EuroSCORE II scale amounted to 2.2±1.2%.

Results. In-hospital mortality in the groups of staged and simultaneous treatment amounted to 1 (0.1%) and 2 (1.3%), respectively. Patients of both groups underwent predominantly eversion carotid endarterectomy (97.8%). The frequency of complications such as postoperative bleeding, postoperative wound infection, stroke and acute myocardial infarction did not differ between groups and amounted to: 14 (2%) and 4 (2.5%) (p=0.410); 5 (0.7%) and 2 (1.2%) (p=0.41); 1 (0.1%) and 1 (0.6%) (р=0.339); 1 (0.1%) and 1 (0.6%) (p=0.339), respectively. In the remote follow-up period (65.1 months) after simultaneous (carotid endarterectomy + coronary artery bypass grafting) and staged (carotid endarterectomy followed by CABG) operations, there were no significant differences in long-term survival - 92.7% vs 89.2% (p=0.437), recurrent myocardial infarction - 8.7% vs 7.7% (p=0.51), and acute ischemic stroke - 5.5% vs 8.2% (p=0.959), respectively.

Conclusion. Simultaneous interventions are indicated for patients presenting with coronary artery disease and significant stenosis of brachiocephalic arteries in unstable angina pectoris, as well as in lesion of the left coronary artery trunk. Staged surgical treatment (first carotid endarterectomy then CABG) is indicated for stable patients with coronary artery disease.

Such differentiated approach makes it possible to perform oeprations for these patients relatively safely and with good efficacy in both the immediate and remote postoperative periods.

Ключевые слова:coronary artery disease; carotid arteries; coronary artery bypass grafting; carotid endarterectomy

Funding. The study had no financial support.

Conflict of interest. The authors declare no conflict of interest.

Authors’ contribution. Study conception and design - Fomenko M.S., Shneider Yu.A., Tsoi V.G.; data collection and handling - Fomenko M.S.; statistical processing - Fomenko M.S.; draft manuscript preparation - Fomenko M.S.; manuscript revision - Shneider Yu.A., Tsoi V.G., Shilenko P.A., Pavlov A.A., Dimitrova I.I.

For citation: Shneider Yu.A., Tsoi V.G., Fomenko M.S., Shilenko P.A., Pavlov A.A., Dimitrova I.I. Simultaneous and staged surgical treatment of carotid artery stenosis in patients with coronary artery disease: remote results. Angiology and Vascular Surgery. 2022; 28 (4): 104-10. DOI: https://doi.org/10.33029/1027-6661-2022-28-4-104-110 (in Russian)

Introduction

Despite advances in operative techniques, acute ischemic stroke (AIS) remains a significant complication of cardiac surgery, with expected event rates of approximately 2% to 4% and is associated with patient’s disability or death. A hemodynamically significant stenosis of brachiocephalic arteries (BCA) is a known independent risk factor for perioperative stroke [1]. According to the current recommendations, cardiosurgical operations should be preceded by selective screening of arterial basins in order to reveal concomitant pathology to be followed by prevention of possible complications, especially in patients with coronary disease. This makes it possible to diagnose significant BCA stenosis prior to coronary artery bypass grafting (CABG) in 2.4-14% of patients [2, 3].

The presence of hemodynamically significant BCA stenosis increases the risk for developing AIS in the perioperative period [1-8]. In such situations, performing carotid endarterectomy (CEA) is an optimal option for of decreasing the risk for AIS. However, the presence of concomitant pathology of coronary arteries results in disputes on selection of an optimal method of treatment of these patients. Analyzing the works devoted to staged and simultaneous surgical treatment of combined lesions of the BCA and coronary artery disease (CAD) demonstrated that a series of publications reported no differences in the incidence rate of AIS and myocardial infarction (MI) in the postoperative period [2, 9]. Other works showed direct dependence of worsened blood circulation in one of the arterial beds in performing as the first stage CABG or CEA [10]. Studies are currently underway to work out a differentiated approach to selecting either staged or simultaneous method of treatment of this patient cohort [11]. Also, significant advantage in prevention of major vascular events was shown in studies devoted to off-pump surgery in CAD. Nevertheless, recommendations on surgical treatment of patients with CAD and significant lesions of the BCA have no clear-cut algorithm of therapeutic decision-making, and the literature continues reporting a clinical balance between simultaneous or staged approach [5, 6, 8]. This circumstance leads to the fact that search for criteria of selecting optimal surgical intervention remains currently important.

Objective. This study was aimed at assessing the results of simultaneous and staged treatment of patients with combined lesions of brachiocephalic arteries and coronary artery disease.

Patients and methods

The study began in 2012, with the patients being recruited retrospectively according to the “continuous observation” [11]. Mortality was chosen as the primary endpoint. Such parameters as MI, AIS and infectious wound complications were defined as secondary endpoints. The indications for surgical treatment were based on the guidelines on myocardial revascularization and surgical treatment of BCA stenoses. Taking into consideration the Good Clinical Practice principles laid down in the Declaration of Helsinki, the patients were informed on the scope of the would-be surgical treatment, signed the informed consent for the operation and processing of the personal data.

From October 2012 to March 2022, we perfumed surgical treatment of 5340 patients with CAD. According to the study design, we included a total of 852 (15.9%) patients with CAD and combined significant BCA lesions (Fig. 1). CEA was considered to be indicated for patients with 70-99% stenosis of the internal carotid artery (ICA).

The main anthropometric and clinical characteristics of patients are shown in Table 1. The mean age in the groups of staged and simultaneous interventions amounted to 67.4±7.4 and 64.2±5.4 years, respectively (form 38 to 84 years). The number of patients over 70 years was 253 (29.7%). The majority of patients were males (606, 71.1%).

Table 1. Anthropometric and clinical characteristics of patients

Operative technique

The decision on the necessity of staged surgical treatment was made based on the patient’s condition. Thus, in stable angina, the patients were assigned to the group of staged treatment, with the first stage being CEA later on followed by second stage CABG. The average interval between hospital admissions amounted to 16.4±13.5 days. Patients with unstable progressing angina or lesions of the left coronary trunk and critical lesions of the BCA were subjected to simultaneous interventions. The overwhelming majority of patients underwent eversion CEA (Fig. 2).

CABG procedures were performed via median sternotomy. The internal thoracic artery (ITA) was exposed in the majority of patients by means of skeletonization (Fig. 3) and was used only for revascularization of the left basin of the heart, the venous graft was procured in the fascial flap in 100% of patients. In normal heart dimensions, preserved ejection fraction, good anatomy and only a proximal lesion of coronary arteries, the operation was performed in conditions of the beating heart, in the remaining patients in artificial circulation both with and without cardioplegia. As cardioplegia, we used the del Nido solution or minicardioplegia. In case of the slightest doubt as to patency of the grafts, we performed heart echocardiography and bypass angiography. Suspecting AIS, we performed angiography and color Doppler mapping of the BCA.

Statistical analysis

The data were statistically analyzed using the Stata/SE 13.0 software package (StataCorp LP, USA). Statistical hypotheses on the type of distribution was tested using the Shapiro-Wilk criterion. The results were expressed as the arithmetic mean and standard deviation (M±SD) for continuous variables, with the categorical values presented as units and percentage (proportions). The statistical significance of differences in the quantitative parameters in the groups were determined using the Mann-Whitney U test. The statistical significance of differences in distribution of frequencies between the groups was calculated according to the chi-square criterion (χ2), if the number of cases was less than 5 in at least one table field we used the two-tailed Fisher test. The шincidence rates of AIS, AMI and survival were analyzed using the Kaplan-Meier method. Differences were regarded as statistically significant if p<0.05.

Results

We analyzed the results of staged and simultaneous treatment of patients with CAD and hemodynamically significant lesions of the ICA. The mean time of the operations and the course of the intra- and postoperative periods are shown Tables 2 and 3.

There were no major cardiovascular events after CEA in the postoperative period. Complications after CEA in separate patients included transient neuropathy of craniocerebral nerves and paroxisms of atrial fibrillation relived medicamentously.

The overall in-hospital mortality amounted to 0.4% (3 patients). Comparing lethality by groups demonstrated no significant difference (p=0.091).

The frequency of such complications as bleeding in the early postoperative period, infection of the postoperative wound, ASI and AMI in the compared groups of patients did not differ either, amounting to 14 (2%) vs 4 (2.5%) (p=0.410); 5 (0.7%) vs 2 (1.2%) (p=0.41); 1 (0.1%) vs 1 (0.6%) (p=0.339); 1 (0.1%) vs 1 (0.6%) (p=0.339), respectively.

During the 30-day postoperative follow-up period, in the group of staged interventions as compared with the simultaneous-intervention group, the developemnt of atrial fibrillation was registered more often - 51 (7.4%) vs 15 (9.4%), respectively. However, the difference turned out statistically insignificant (p=0.377). CABG was reliably longer in the group of staged interventions (p<0.001). ICU stay did not statistically differ between the groups, amounting to 1.6±0.6 and 1.7±0.7 days, respectively (p=0.337). Analyzing the overall length of hospital stay demonstrated that it was reliably longer in the group of staged interventions, amounting to 18.6±3.1 vs 14.1±5.1 days (p<0.001).

In the remote period we examined 95% of patients. The average duration of follow-up for the staged and simultaneous interventions amounted to 65 months (95% CI 64.2-65.6) and 62.6 months (95% CI 61-64.3), respectively.

Patients’ survival (Kaplan-Meier method) for the group of staged and simultaneous interventions at 12, 36 and 60 months turned out to amount to 99.4% (95% CI 98.4-99.7), 95.1% (95% CI 93.1-96.4), 89.2% (95% CI 84.3-92.5) and 98.1% (95% CI 95.1-99.6), 96.8% (95% CI 92.5-98.6), 92.7% (95% CI 84.1-96.7), respectively (Fg. 4, A). Hence, there was no significant difference between groups for survival (Log-rank test, p=0.437).

We additionally analysed the incidence of AMI and AIS in the remote period according to the Kaplan-Meier method, demonstrating that the AMI incidence rate in the remote period for the staged and simultaneous interventions at 12, 36 and 60 months amounted to 0.5% (95% CI 0.2-1.5), 1.4% (95% CI 0.8-2.7), 7.7% (95% CI 4.8-12) and 0.2% (95% CI 1.4-6.8), 8.7% (95% CI 4-18.4), respectively (Log-rank test, p=0,501) (Fig. 4, B). The incidence rate of AIS in the remote period in the groups of staged and simultaneous interventions at 12, 36 and 60 months amounted to 1.3% (95% CI 0.7-2.6), 8.2% (95% CI 4.9-13.6) and 1.3% (95% CI 0.3-5.1), 5.5% (95% CI 1.5-18.8), respectively (Log-rank test, p=0.959) (Fig. 4, C).

Discussion

Presented herein are the retrospective results of a single-center study, demonstrating the outcomes of staged and simultaneous interventions in patients with combined lesions of BCA and CAD.

Apparently, combined lesions of BCA and CAD lead to increased incidence of possible AIS in the postoperative period. According to the current guidelines, such patients are eligible candidates to undergo either staged (with CEA first) or simultaneous intervention (class II b/c) [8]. However, no criteria for selection between simultaneous or staged surgical intervention have yet been determined.

In clinical practice, there remains a relative equilibrium between the groups concerned. Thus, some authors in their retrospective analyses demonstrated no significant difference in 30-day clinical outcomes for AIS, AMI and mortality while performing either staged or simultaneous interventions [1, 12-14]. Other studies showed a direct correlation between AIS development in the postoperative period and severity of BCA stenosis and singled out three groups: group 1 - 50-79% stenosis of the internal carotid artery (ICA), risk = 0; group 2 - ≥80% ICA stenosis or occlusion of one ICA, risk - 3.8%; and group 3 - bilateral ≥ 80% ICA stenosis, risk - 8.3% [15, 16]. Other authors carrying out multifactorial analysis demonstrated that a risk factor of vascular catastrophes was a simultaneous approach associated with an increased risk of developing AMI and AIS up to 40% [17, 18]. Previously performed meta-analyses, prospective randomized studies reported no significant differences in the incidence rate of AIS and mortality after CABG in patients with concomitant symptom-free BCA stenoses [1, 2].

In our study, the 30-day clinical outcomes by the incidence of AIS and AMI coincided with the conclusions of A.R. Naylor and A.A. Dönmez who demonstrated no statistically significant difference in the groups of staged and simultaneous treatment [12, 13].

The most disputable problem remains the time interval between CEA and CABG in staged surgical treatment of patients with significant BCA lesion and CAD. Thus, it was shown that median staging interval between CEA and cardiac surgery was 52.3 days [19]. In our study, based on assessment of the patient’s clinical state and calculations of the risk for developing major cardiovascular events, the minimal and maximal period between the stages amounted to 5 and 46 days, respectively.

Long-term survival according to the Kaplan-Meier method had no statistically significant difference between the groups of staged and simultaneous interventions (log rank test, p=0.437) and amounted at 60 months to 89.2% (95% CI 84.3-92.5) and 92.7% (95% CI 84.1-96.7), respectively. An additionally performed analysis of the incidence of AMI and AIS also showed no statistically significant difference (log-rank test, p=0.501 and log-rank test, p=0.959, respectively). The obtained long-term results correlate with the majority of previous studies. The analysis showed no differences between the groups in the incidence rate of postoperative complications, which did not exceed those demonstrated in previously published works. We believe that this is most likely related to differentiated surgical policy based on clinical assessment of the state of each patient. In such approach, the obtained results demonstrate safety and efficacy of both staged and simultaneous surgical treatment of patients with combined lesions of BCA and CAD.

Conclusion

Simultaneous interventions are indicated for patients with CAD and significant BCA stenosis in unstable angina, as well as LCA trunk lesions. Staged surgical treatment (first CEA then CABG) is indicated for patients with stable CAD.

Such differentiated approach makes it possible to perform operations in these patients relatively safely with good efficacy in both immediate and remote postoperative periods.

The use of the differentiated approach in the choice of the staging of treatment and conditions of carrying out operations (beating heart, parallel AC, AC with cardioplegia) makes it possible to additionally improve the results of treatment.

Limitation. This study was single-center, retrospective. The obtained results may be considered for a similar cohort of patients, with the follow-up not exceeding 5 years. Completeness of the study requires the assessment of remote results for 10-15 years.

References

1. Klarin D., Patel V.I., Zhang S., et al. Concomitant carotid endarterectomy and cardiac surgery does not decrease postoperative stroke rates. Journal of Vascular Surgery. 2020; 72 (2): 589-596. DOI: https://doi.org/10.1016/j.jvs.2019.10.072

2. Giannopoulos S., Texakalidis P., Charisis N., et al. Synchronous Carotid Endarterectomy and Coronary Artery Bypass Graft (CABG) versus staged Carotid Artery Stenting and CABG for Patients with Concomitant Severe Coronary and Carotid Stenosis: a Systematic Review and Meta-analysis. Annals of Vascular Surgery. 2020; 62: 463-473. DOI: https://doi.org/10.1016/j.avsg.2019.06.018

3. Saedi S., Ghadrdoost B., Pouraliakbar H., et al. The association between increased carotid intima-media thickness and SYNTAX Score in coronary artery disease: A single center study. Indian Heart Journal. 2018; 70 (5): 627-629. DOI: https://doi.org/10.1016/j.ihj.2018.01.010

4. Sousa P.P., Teixeira G., Gonçalves J., et al. Carotid Stenosis in Cardiac Surgery Patients. Revista portuguesa de cirurgia cardio-toracica e vascular. 2017; 24 (3-4): 126.

5. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2016; 134 (10): 123-155. DOI: https://doi.org/10.1161/CIR.0000000000000404

6. Naylor A.R., Ricco J.B. Response to “Re: Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)”. European Journal of Vascular and Endovascular Surgery. 2018; 55 (6): 902. DOI: https://doi.org/10.1016/j.ejvs.2018.03.023

7. Aronow H.D., Collins T.J., Gray W.A., et al. SCAI/SVM expert consensus statement on carotid stenting: Training and credentialing for carotid stenting. Catheterization and Cardiovascular Interventions. 2016; 87 (2): 188-199. DOI: https://doi.org/10.1002/ccd.26304

8. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery Developed in Collaboration With the American Academy of Neurology and Society of Cardiovascular Computed Tomography. Catheterization and Cardiovascular Interventions. 2013; 81 (1): 76-123. DOI: https://doi.org/10.1002/ccd.22983

9. Belov Yu.V., Bayandin N.L., Kosenkov A.N., et al. Simultaneous operations of patients with combined lesions of the coronary and brachiocephalic arteries. Angiology and Vascular Surgery. 1995; 1 (3): 35-45. (in Russian)

10. Likosky D.S., Marrin C.A.S., Caplan L.R., et al. Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery. Stroke. 2003; 34 (12): 2830-2834. DOI: https://doi.org/10.1161/01.STR.0000098650.12386.B3

11. Schneider Y.A., Tsoi V.G., Fomenko M.S., et al. Surgical treatment for coronary artery disease with concomitant carotid stenosis: one-center experience. Almanac of Clinical Medicine. 2019; 47 (4): 318-325. DOI: https://doi.org/10.18786/2072-0505-2019-47-046. (in Russian)

12. Naylor A.R. Synchronous Cardiac and Carotid Revascularisation: The Devil is in the Detail. European Journal of Vascular and Endovascular Surgery. 2010; 40 (3): 303-308. DOI: https://doi.org/10.1016/j.ejvs.2010.05.017

13. Dönmez A.A., Adademir T., Sacli H., et al. Comparison of Early Outcomes with Three Approaches for Combined Coronary Revascularization and Carotid Endarterectomy. Brazilian Journal of Cardiovascular Surgery. 2016; 31 (5): 365-370. DOI: https://doi.org/10.5935/1678-9741.20160076

14. Idris M. A., Cummings B, Sullivan J. The risk of cerebrovascular accident in patients with asymptomatic critical carotid artery stenosis who undergo open-heart surgery. Canadian Journal of Surgery. 1998; 41 (5): 374-378.

15. Schwartz L.B., Bridgman A.H., Kieffer R.W., et al. Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass. Journal of Vascular Surgery. 1995; 21 (1): 146-153. DOI: https://doi.org/10.1016/s0741-5214(95)70253-9

16. Salasidis G., Latter D., Steinmetz O. Carotid artery duplex scanning in preoperative assessment for coronary artery revascularization: the association between peripheral vascular disease, carotid artery stenosis, and stroke. Journal of Vascular Surgery. 1995; 21 (1): 154-160. DOI: https://doi.org/10.1016/s0741-5214(95)70254-7

17. Prasad S.M., Li S., Rankin J.S., et al. Current outcomes of simultaneous carotid endarterectomy and coronary artery bypass graft surgery in North America. World Journal of Surgery. 2010; 34 (10): 2292-2298. DOI: https://doi.org/10.1007/s00268-010-0506-4

18. National guidelines for the management of patients with brachiocephalic artery diseases. М. 2013; 72. (in Russian)

19. Birchley D., Villaquiran J., Akowuah E., et al. Staged carotid endarterectomy under local anaesthetic in patients requiring cardiac surgery. Annals of the Royal College of Surgeons of England. 2010; 92 (5): 373-378. DOI: https://doi.org/10.1308/003588410X12628812459850

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Доктор медицинских наук, профессор, академик РАН, заместитель генераль­ного директора по хирургии, руководитель отдела сердечно-сосудистой хирургии ФГБУ «НМИЦ кардиологии им. акад. Е.И. Чазова» Минздрава России, президент Российского общества ангиологов и сосудистых хирургов

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