February 27, 2017
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Risks for stroke, death vary with endarterectomy vs. carotid stenting in patients with CAD, carotid artery disease

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Carotid endarterectomy was associated with a twofold higher risk for death but a significantly lower risk for stroke vs. carotid artery stenting in patients with concomitant carotid and coronary disease undergoing CABG.

Researchers evaluated the odds of death, stroke, and death or stroke associated with three strategies for combined revascularization in patients with concomitant carotid and coronary disease: carotid endarterectomy performed simultaneously with CABG, staged carotid endarterectomy plus CABG and staged CAS plus CABG. The analysis included data from the 2004 to 2012 Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Nationwide Inpatient Sample files.

Of the 22,501 patients who underwent CABG and carotid revascularization during the same hospitalization, 68.4% underwent simultaneous endarterectomy, 28% underwent staged endarterectomy and 3.6% underwent staged CAS. Patients undergoing CAS plus CABG tended to be higher risk, with asymptomatic carotid disease and more CV morbidities.

From 2004 to 2012, the rate of CAS plus CABG did not change significantly, but the overall rate of endarterectomy plus CABG during the same hospitalization decreased by 16.1% (P for trend = .03).

Adjusted mortality risk was significantly higher for simultaneous endarterectomy plus CABG (OR = 2.08; 95% CI, 1.08-3.97) and staged endarterectomy plus CABG (OR = 2.4; 95% CI, 1.43-4.05) vs. staged CAS plus CABG. Risk for stroke, however, was significantly lower with simultaneous endarterectomy plus CABG (OR = 0.65; 95% CI, 0.42-1.01) and staged endarterectomy plus CABG (OR = 0.5; 95% CI, 0.31-0.8) vs. staged CAS plus CABG. The three groups had similar adjusted risk for death or stroke.

The researchers also divided the cohorts into two time periods — 2004 to 2008 and 2009 to 2012 — to assess the effect of operator learning curve on the study endpoints. They found an improvement in risk for death (adjusted OR = 0.75; P = .002) and death or stroke (adjusted OR = 0.8; P = .002) over time in the simultaneous endarterectomy plus CABG group. However, the greatest improvements over time were noted in the CAS plus CABG group, with adjusted ORs of 0.19 (P = .04) for death and 0.33 (P = .01) during 2009 to 2012 vs. 2004 to 2008.

“Future studies are needed to examine the risks–benefits of different carotid revascularization strategies for high-risk patients requiring concurrent CABG,” the researchers wrote. – by Melissa Foster

Disclosure: One researcher reports being a consultant/speaker bureau member for Abbott Vascular, Medtronic and St. Jude Medical.