title: Carotid Stenting Prior to Coronary Bypass Surgery: An Updated Systematic Review and Meta-Analysis.
abstract: OBJECTIVE
  The aim was to determine 30-day outcomes in patients with concurrent carotid and cardiac disease who underwent carotid artery stenting (CAS) followed by coronary artery bypass grafting (CABG).
  
  
  METHODS
  This was a systematic review with searches of PubMed/Medline, Embase, and Cochrane databases. "Same-day" procedures involved CAS + CABG being performed on the same day, and "staged" interventions involved at least 1 day's delay between undergoing CAS and then CABG.
  
  
  RESULTS
  There were 31 eligible studies (2727 patients), with 80% being neurologically asymptomatic with unilateral stenoses. Overall, the 30-day death/stroke rate was 7.9% (95% confidence interval [CI] 6.9-9.2), while death/stroke/MI was 8.8% (95% CI 7.3-10.5). Staged CAS + CABG was associated with 30-day death/stroke rate of 8.5% (95% CI 7.3-9.7) compared with 5.9% (95% CI 4.0-8.5) after "same-day" procedures. Outcomes following CAS + CABG in neurologically symptomatic patients were poorer, with procedural stroke rates of 15%. There were five antiplatelet (APRx) strategies: (a) no APRx (death/stroke/MI, 4.2%; no data on bleeding complications); (b) single APRx before CAS and CABG, then dual APRx after CABG (death/stroke/MI, 6.7%; 7.3% bleeding complications); (c) dual APRx pre-CAS down to one APRx pre-CABG (death/stroke/MI, 10.1%; 2.8% bleeding complications); (d) dual APRx pre-CAS, both stopped pre-CABG (death/stroke/MI, 14.4%); (e) dual APRx pre-CAS and continued through CABG (death/stroke/MI, 16%). There were insufficient data on bleeding complication in the last two strategies.
  
  
  CONCLUSIONS
  In a cohort of predominantly asymptomatic patients with unilateral carotid stenoses, the 30-day rate of death/stroke was about 8%. Notwithstanding the effect of potential biases, this meta-analysis did not find evidence that outcomes after same-day CAS + CABG were higher than after staged interventions. However, outcomes were poorer in neurologically symptomatic patients. More data are required to establish the optimal antiplatelet strategy in patients undergoing same-day or staged CAS + CABG.
authors.affiliation: The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
authors.forename: K I
authors.initials: KI
authors.lastname: Paraskevas
authors.affiliation: The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
authors.forename: S
authors.initials: S
authors.lastname: Nduwayo
authors.affiliation: The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
authors.forename: A N
authors.initials: AN
authors.lastname: Saratzis
authors.affiliation: The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK. Electronic address: ross.naylor@uhl-tr.nhs.uk.
authors.forename: A R
authors.initials: AR
authors.lastname: Naylor
mesh_terms: D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors
keywords: Asymptomatic carotid disease; Carotid artery stenting; Carotid endarterectomy; Stroke