title: Treatment strategies in severe symptomatic carotid and coronary artery disease.
abstract: Coexistent carotid artery stenosis (CS) and multivessel coronary artery disease (CAD) is not infrequent. One in 5 patients with multivessel CAD has a severe CS, and CAD incidence reaches 80% in those referred for carotid revascularization. We reviewed treatment strategies for concomitant severe CS and CAD. We performed a literature search (MEDLINE) with terms including carotid artery stenting (CAS), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), stroke, and myocardial infarction (MI). The main therapeutic option for CS-CAD has been (simultaneous or staged) CEA-CABG. This, however, is associated with a high risk of MI (in those with CEA prior to CABG) or stroke (CABG prior to CEA), and the cumulative major adverse event rate (MAE - death, stroke or MI) reaches 10-12%. With increasing adoption of CAS, a sequential strategy of CAS followed by CABG has emerged. Registries (usually single-centre) indicate an MAE rate of ≈7% for CAS followed by CABG (frequently after >30 days, due to double antiplatelet therapy). Recently, 1-stage CAS-CABG has been introduced. This involves different antiplatelet regimens and, in some centers, preferred off-pump CABG, with a cumulative MAE of 1.4-4.5%. No randomized trial comparing different treatment strategies in CS-CAD has been conducted, and thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-centre, studies are required before this can become widely applied.
authors.affiliation: Department of Cardiac and Vascular Diseases, Jagiellonian University, Cracow, Poland. kdzierwa@gmail.com
authors.forename: Karolina
authors.initials: K
authors.lastname: Dzierwa
authors.forename: Piotr
authors.initials: P
authors.lastname: Pieniazek
authors.forename: Piotr
authors.initials: P
authors.lastname: Musialek
authors.forename: Jacek
authors.initials: J
authors.lastname: Piatek
authors.forename: Lukasz
authors.initials: L
authors.lastname: Tekieli
authors.forename: Piotr
authors.initials: P
authors.lastname: Podolec
authors.forename: Rafał
authors.initials: R
authors.lastname: Drwiła
authors.forename: Marta
authors.initials: M
authors.lastname: Hlawaty
authors.forename: Mariusz
authors.initials: M
authors.lastname: Trystuła
authors.forename: Rafał
authors.initials: R
authors.lastname: Motyl
authors.forename: Jerzy
authors.initials: J
authors.lastname: Sadowski
mesh_terms: D002340:Carotid Artery Diseases / Q000150:complications / Q000628:therapy*; D002986:Clinical Trials as Topic; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000150:complications / Q000628:therapy*; D016894:Endarterectomy, Carotid; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology; D015607:Stents; D020521:Stroke / Q000209:etiology