Coronary Artery Disease: Bell PR

Liapis CD, Bell PR, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, Biasi G, Norgren L, Anonymous00081. · Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece. · Eur J Vasc Endovasc Surg. · Pubmed #19286127 No free full text.

Abstract: The European Society for Vascular Surgery brought together a group of experts in the field of carotid artery disease to produce updated guidelines for the invasive treatment of carotid disease. The recommendations were rated according to the level of evidence. Carotid endarterectomy (CEA) is recommended in symptomatic patients with >50% stenosis if the perioperative stroke/death rate is <6% [A], preferably within 2 weeks of the patient's last symptoms [A]. CEA is also recommended in asymptomatic men <75 years old with 70-99% stenosis if the perioperative stroke/death risk is <3% [A]. The benefit from CEA in asymptomatic women is significantly less than in men [A]. CEA should therefore be considered only in younger, fit women [A]. Carotid patch angioplasty is preferable to primary closure [A]. Aspirin at a dose of 75-325 mg daily and statins should be given before, during and following CEA. [A] Carotid artery stenting (CAS) should be performed only in high-risk for CEA patients, in high-volume centres with documented low peri-operative stroke and death rates or inside a randomized controlled trial [C]. CAS should be performed under dual antiplatelet treatment with aspirin and clopidogrel [A]. Carotid protection devices are probably of benefit [C].

Naylor R, Cuffe RL, Rothwell PM, Loftus IM, Bell PR. · Department of Vascular Surgery at Leicester Royal Infirmary, Clinical Neurology, The Radcliffe Infirmary, P.O. Box 65, Leicester Royal Infirmary, Leicester, U.K. · Eur J Vasc Endovasc Surg. · Pubmed #14509884 No free full text.

Abstract: OBJECTIVES: Outcomes after synchronous carotid endarterectomy (CEA) plus coronary artery bypass (CABG) relative to surgical and patient based variables. DESIGN: Systematic review of 94 published series (7863 synchronous procedures). RESULTS: 11.5% of patients died or suffered a stroke/myocardial infarction in the peri-operative period (95% CI 10.1-12.9). The risk of death/stroke appeared to significantly diminish in studies published between 1993-2002, compared with 1972-1992 (7.2% (95% CI 6.5-9.1) versus 10.7% (95% CI 8.9-12.5), p = 0.03). However, increasing operative experience was not associated with significantly lower risks of death/stroke; (1-49 cases (9.6% (95% CI 7.5-11.8); 50-99 cases (9.1% (95% CI 6.4-11.8); 100+ cases (8.4% (95% CI 6.9-10.1) (p = 0.64)). Patients with severe bilateral carotid disease were significantly more likely to suffer death and/or stroke compared to patients with unilateral disease (odds ratio 2.5, 95% CI 1.4-5.0, p = 0.001). Similarly, patients with a prior history of stroke/transient ischaemic attack (TIA) were significantly more likely to suffer a further stroke than asymptomatic patients (odds ratio 1.8, 95% CI 1.1-2.8, p = 0.008). There was no difference in the risk of death/stroke relative to the timing of CEA (pre- versus on-cardiopulmonary bypass), but recent small studies indicate that improved outcomes might be achieved by performing CABG 'off-bypass'. CONCLUSIONS: Synchronous CEA + CABG is associated with a not insignificant cardiovascular risk. No comparable information is available for similar patients undergoing CABG without prophylactic CEA.

Naylor AR, Bell PR. · Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, UK. · J Cardiovasc Surg (Torino). · Pubmed #12832991 No free full text.

Abstract: The management of patients with combined carotid and coronary artery disease remains controversial, largely because of a lack of high quality natural history studies in patients with asymptomatic carotid disease undergoing isolated coronary artery bypass surgery. To date, practice ranges from never recommending additional intervention to a more aggressive policy of prophylactic carotid endarterectomy. For surgeons in the latter group, the only remaining debate is whether CEA should be staged or synchronous. This paper reviews the rationales and available evidence for managing the cardiac patient with asymptomatic carotid disease and is largely based on the findings of 2 recently published systematic re-views on the subject. These reviews suggest that a reappraisal of practice is necessary before the indiscriminate implementation of carotid angioplasty further complicates interpretation of the already poor quality data available.

Naylor AR, Cuffe RL, Rothwell PM, Bell PR. · Department of Vascular Surgery, Clinical Sciences Building, PO Box 65, Leicester Royal Infirmary, Leicester LE2 7LX, UK. · Eur J Vasc Endovasc Surg. · Pubmed #12713775 No free full text.

Abstract: OBJECTIVES: to determine the overall cardiovascular risk for patients with combined cardiac and carotid artery disease undergoing synchronous coronary artery bypass (CABG) and carotid endarterectomy (CEA), staged CEA then CABG and reverse staged CABG then CEA. DESIGN: systematic review of 97 published studies following 8972 staged or synchronous operations. RESULTS: mortality was highest in patients undergoing synchronous CEA+CABG (4.6%, 95% CI 4.1-5.2). Reverse staged procedures (CABG-CEA) were associated with the highest risk of ipsilateral stroke (5.8%, 95% CI 0.0-14.3) and any stroke (6.3%, 95% CI 1.0-11.7). Peri-operative myocardial infarction (MI) was lowest following the reverse staged procedure (0.9%, 95% CI 0.5-1.4) and highest in patients undergoing staged CEA-CABG (6.5%, 95% CI 3.2-9.7).The risk of death+/-any stroke was highest in patients undergoing synchronous CEA+CABG (8.7%, 95% CI 7.7-9.8) and lowest following staged CEA-CABG (6.1%, 95% CI 2.9-9.3). The risk of death/stroke or MI was 11.5% (95% CI 10.1-12.9) following synchronous procedures versus 10.2% (95% CI 7.4-13.1) after staged CEA then CABG. CONCLUSIONS: 10-12% of patients undergoing staged or synchronous procedures suffered death or major cardiovascular morbidity (stroke, MI) within 30 days of surgery. Overall, there was no significant difference in outcomes for staged and synchronous procedures and no comparable data for patients with combined cardiac and carotid disease not undergoing staged or synchronous surgery.

Naylor AR, Mehta Z, Rothwell PM, Bell PR. · Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, UK. · Eur J Vasc Endovasc Surg. · Pubmed #11991687 No free full text.

Abstract: OBJECTIVES: to determine the role of carotid artery disease in the pathophysiology of stroke after coronary artery bypass (CABG). DESIGN: systematic review of the literature. RESULTS: the risk of stroke after CABG was 2% and remained unchanged between 1970-2000. Two-thirds occurred after day 1 and 23% died. 91% of screened CABG patients had no significant carotid disease and had a <2% risk of peri-operative stroke. Stroke risk increased to 3% in predominantly asymptomatic patients with a unilateral 50-99% stenosis, 5% in those with bilateral 50-99% stenoses and 7-11% in patients with carotid occlusion. Significant predictive factors for post-CABG stroke included; (i) carotid bruit (OR 3.6, 95% CI 2.8-4.6), (ii) prior stroke/TIA (OR 3.6, 95% CI 2.7-4.9) and (iii) severe carotid stenosis/occlusion (OR 4.3, 95% CI 3.2-5.7). However, the systematic review indicated that 50% of stroke sufferers did not have significant carotid disease and 60% of territorial infarctions on CT scan/autopsy could not be attributed to carotid disease alone. CONCLUSIONS: carotid disease is an important aetiological factor in the pathophysiology of post-CABG stroke. However, even assuming that prophylactic carotid endarterectomy carried no additional risk, it could only ever prevent about 40-50% of procedural strokes.