title: Early results after synchronous carotid stent placement and coronary artery bypass graft in patients with asymptomatic carotid stenosis.
abstract: BACKGROUND
  The optimal management of patients with combined carotid and coronary artery disease requiring cardiac surgery is still unknown. Staged carotid endarterectomy and carotid artery stenting (CAS), each followed by coronary artery bypass graft (CABG), are options frequently employed. However, for patients with severe carotid artery disease in urgent need of open cardiac revascularization, staged operations may not be the most appropriate alternative. The aim of this study was to describe our experience using a synchronous CAS-CABG method with minimal interprocedural time. We used this synchronous combination of procedures in patients with combined carotid and coronary artery disease admitted for urgent CABG.
  
  
  METHODS
  Patients with concomitant severe carotid and coronary artery disease scheduled for synchronous CAS and urgent CABG between December 2006 and January 2010 were included in the study. All procedures were performed at a single center: the Cardiovascular Foundation of Colombia, in Floridablanca, Santander, Colombia. The study cohort was characterized according to demographic and clinical characteristics, which included degree of carotid stenosis, presence/absence of preoperative neurological symptoms, and cardiac operative risk profile. All patients underwent CAS under embolic protection devices and then CABG within the next 2 hours. Patients received aspirin pre- and postprocedure but were started on clopidogrel only after CABG. The primary end point of the study was the composite incidence rate of myocardial infarction, stroke, and death 30 days after CAS-CABG.
  
  
  RESULTS
  Fifteen patients with concomitant severe carotid and coronary artery disease underwent synchronous CAS-CABG. Most patients (60%) were men, and mean (± standard deviation) age was 65.2 (± 8.4) years. Most patients (93%) were neurologically asymptomatic. The median (interquartile range) ejection fraction and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) for the cohort were 55% (36%-62%) and 9.7% (4.6%-14.8%), respectively. There were no deaths, major strokes, minor strokes, or myocardial infarctions during the procedure or within 30 days of CAS-CABG. One patient experienced neurological symptoms likely as a result of transient ischemic attack ipsilateral to the CAS procedure. None of the patients required cardiac or carotid reinterventions, and there were no cases of postoperative bleeding requiring reoperation.
  
  
  CONCLUSIONS
  Synchronous CAS-CABG, when CABG is performed within the 2 hours of the CAS procedure, may be a viable alternative to the more generally accepted staged combination, particularly among patients for whom CABG cannot be postponed. We hope that this strategy will be further evaluated in larger prospective studies and adequately powered randomized clinical trials.
authors: Department of Cardiovascular Surgery, Division of Vascular and Endovascular Surgery, Fundación Cardiovascular de Colombia, Santander, Colombia. juanbarrera@fcv.org
authors: Juan Guillermo
authors: JG
authors: Barrera
authors: Kristin E
authors: KE
authors: Rojas
authors: Carlos
authors: C
authors: Balestrini
authors: Camilo
authors: C
authors: Espinel
authors: Antonio
authors: A
authors: Figueredo
authors: Jose Federico
authors: JF
authors: Saaibi
authors: Santiago
authors: S
authors: Machuca
authors: Adriana
authors: A
authors: Murcia
mesh_terms: D000368:Aged; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D058070:Asymptomatic Diseases; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D003105:Colombia; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D057505:Embolic Protection Devices; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D012720:Severity of Illness Index; D015607:Stents; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome