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01 August 2011

Treatment strategies in severe symptomatic carotid and coronary artery disease

Karolina Dzierwa, Piotr Pieniazek, Piotr Musialek, Jacek Piatek, Lukasz Tekieli, Piotr Podolec, Rafal Drwila, Marta Hlawaty, Mariusz Trystula, Rafal Motyl, Jerzy Sadowski

DOI: 10.12659/MSM.881896

Med Sci Monit 2011; 17(8): RA191-197

Abstract

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.

Keywords: Myocardial Infarction - etiology, Endarterectomy, Carotid, Coronary Artery Disease - therapy, Coronary Artery Bypass, Clinical Trials as Topic, Carotid Artery Diseases - therapy, Stents, Stroke - etiology

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