Treatment of Carotid Artery Stenosis by Elective Stent Placement Instead of Carotid Endarterectomy in Patients with Severe Coronary Artery Disease

Summary

Patients with concomitant cardiac and cerebrovascular disease undergoing revascularization procedures are at high risk of both, cardiac and cerebrovascular complications. The purpose of our study was to evaluate the feasibility of prior elective carotid artery stenting as an alternative treatment procedure to carotid endarterectomy (CEA) in patients with concomitant coronary artery disease (CAD), who clearly needed coronary revascularization. We offered extracranial internal carotid stenting to 85 patients with 89 significant carotid stenoses. Out of these, 19 patients were symptomatic. The quantitative mean reduction in diameter was 77 ± 11%. Stent implantation was successful in 88 lesions. Two disabling major and 3 reversible minor strokes occurred periprocedurally. Three patients showed asymptomatic restenosis and stent deformation was detected in 2 patients. Based on this experience, carotid stenting in high risk patients with severe coronary artery disease is feasible and safe and might be indicated as an alternative procedure for combined surgery.

Key words

Carotid stenosis - coronary artery disease - carotid endarterectomy - carotid stenting

• References

• 1 Hurst RW. Carotid angioplasty. Radiology 1996; 201: 613-6.
• 2 DeBakey ME. Carotid endarterectomy revisited. J Endovasc Surg. 1996 3. (1) 4.
• 3 North American Symptomatic Carotid Endarterctomy Trial Collaboration. Beneficial effect of carotid endarterectomy in symptomatic patients with high grade carotid stenosis. N Eng J Med 1991; 325: 445-53.
• 4 European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 1991; 337: 1235-43.
• 5 Rothwell PM, Warlow CP. Carotid endarterectomy in patients with recently symptomatic moderate (30-69%) carotid stenosis: no overall benefit. Eur Heart J 1997; 18: 355-6.
• 6 Executive Committe for the Asymptomatic Carotid Atherosclerosis Study. Endarterctomy for asymptomatic carotid artery stenosis. JAMA 1995; 273: 1421-8.
• 7 Brener BJ, Brief DK, Alpert J, Goldenkranz RJ, Parsonnet V. The risk of stroke in patients with asymptomatic carotid stenosis undergoing cardiac surgery; a follow-up study. J Vasc Surg 1987; 5: 269-79.
• 8 Faggioli CL, Curl G, Ricotta JJ. The role of carotid screening before coronary artery surgery. J Vasc Surg 1990; 12: 724-31.
• 9 Hertzer NR, Loop FD, Beven EG. Surgical staging for simultaneous coronary and carotid disease: a study including prospective randomization. J Vasc Surg 1989; 9: 455-63.
• 10 Roach GW, Kanchuger M, Mangano CM, Newman M, Nussmeier N, Wolman R, Aggarwal A, Marschall K, Graham SH, Ley C, Ozanne G, Mangano DT. for the Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators Adverse cerebral outcomes after coronary bypass surgery. New Engl J Med 1996; 335: 1857-63.
• 11 Moore WS, Barnett HJM, Beebe HG, Bernstein EF, Brener BJ, Brott T, Caplan LR, Day A, Goldstone J, Hobson 2nd RW, Kempczinski RF, Matchar DB, Mayberg MR, Nicolaides AN, Norris JW, Ricotta JJ, Robertson JT, Ritherford RB, Thomas D, Toole JF, Trout III HH, Wiebers DO. Guidlines for Carotid Endarterectomy. A Multidisciplinary Consensus Statement From the Ad Hoc Committee, American Heart Association. Circulation 1995; 91: 566-79.
• 12 Yadav JS, Roubin GS, Iyer S, Vitek J, King P, Jordan WD, Fisher WS. Elective Stenting of the Extracranial Carotid Arteries. Circulation 1997; 95: 376-81.
• 13 Roubin GS, Yadav S, Iyer SS, Vitek J. Carotid stent-supported angioplasty: a neurovascular intervention to prevent stroke. Am J Cardiol 1996; 78 (Suppl 3A) 8-12.
• 14 Rizzo RJ, Whittemore AD, Couper GS, Donaldson MC, Aranki SF, Collind Jr. JJ, Mannick JA, and Cohn LH. Combined carotid and coronary revascularization: the preferred approach to the severe vasculopath. Ann Thorac Med 1992; 54: 1099-109.
• 15 Reed III GL, Singer DE, Picard EH, DeSanctis RW. Stroke following coronary-artery bypass surgery: a case-control estiamte of the risk from carotid bruits. N Engl J Med 1988; 319: 1246-50.
• 16 Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, Caplan LR, Kresowik TF, Matchar DB, Toole JF, Easton JD, Adams Jr. HP, Brass LM, Hobson 2nd RW, Brott TG, Sternau L. Guidlines for Carotid Endarterectomy: A Statement for Healthcare Professionals From Writing Group of the Stroke Council, American Heart Association. Circulation 1998; 97: 501-9.
• 17 Beebe HG, Archie JP, Baker WH, Barnes RW, Becker GJ, Bernstein EF, Brener B, Clagett GP, Clowes AW, Cooke JP, Creager MA, Cronenwett JL, Dake M, DeWeese JA, Fogarty TJ, Freischlag JA, Goldstone J, Greenfield LJ, Hertzer NR, Hobson RW, Joyce JW, Katzen BT, LoGerfo FW, Mohr JP, Moore WS, Janafi H, Ricotta JJ, Riles TS, Ring EJ, Robertson J, Rutherford RB, Sos T, Stanley JC, Strandness DE, Sumner DS, Toole J, Towne JB, Veith FJ, Whittemore AD, Yao JST, Zarins CK. Concerns about safety of carotid angioplasty. Stroke 1996; 27: 197-8.
• 18 Grotta J. Elective stenting of extracranial carotid arteries. Circulation 1997; 95: 303-5.
• 19 Roubin GS, Yadav S, Iyer SS, Vitek J. Carotid stent-supported angioplasty: a neurovascular intervention to prevent stroke. Am J Cardiol 1996; 78 (Suppl 3A) 8-12.
• 20 Waigand J, Gross CM, Uhlich F, Kr«mer J Tamaschke C, Vogel P, Luft FC, Dietz R. Elective stenting of carotid artery stenosis in patients with severe coronary artery disease. Eur Heart J 1998; 19: 1365-70.
• 21 Wholey MH, Wholey M, Bergeron P, Diethrich EB, Henry M, Laborde JC, Mathias K, Subbarao M, Roubin GS, Shawl F, Theron JG, Yadav JS, Dorros G, Giumaraens J, Higashida R, Kumar V, Leon M, Lim M, Londero H, Mesa J, Ramee S, Rodriguez A, Rosenfiled K, Teiletlbaum G, Vozzi C. Current Global Status of Carotid Artery Stent Placement. Catheterization and Cardiovascular Diagnosis 1998; 44: 1-6.
• 22 Bettman MA, Katzen BT, Whisnat J, Brant-Zawadzki M, Broderick JP, Furlan AJ, Hershey LA, Howard V, Kuntz R, Loftus CM, Pearce W, Roberts A, Roubin G. Carotid Stenting and Angioplasty. A Statement for Healthcare Professionals From the Coucils on Cardiovascular Radiology, Stroke, Cardio-Thoracic and Vasczular Surgery, Epidemiology and Prevention, and Clinical Cardiology, American Heart Association. Circulation 1998; 97: 121-3.