Meta-Analysis Evaluates CAS Before CABG
January 18, 2017—Online in the European Journal of Vascular and Endovascular Surgery (EJVES), Kosmas I. Paraskevas, MD, et al published a study on 30-day outcomes of patients with concurrent carotid and cardiac disease who underwent carotid artery stenting (CAS) followed by coronary artery bypass grafting (CABG).
The systematic review involved searches of PubMed/Medline, Embase, and Cochrane databases. “Same-day” procedures involved CAS plus CABG being performed on the same day, and “staged” interventions involved a delay of at least 1 day between undergoing CAS and then CABG. There were 31 eligible studies (2,727 patients), with 80% being neurologically asymptomatic with unilateral stenoses.
In the study's conclusions, the investigators reported that in a cohort of predominantly asymptomatic patients with unilateral carotid stenoses, the 30-day rate of death/stroke was approximately 8%. Notwithstanding the effect of potential biases, this meta-analysis did not find evidence that outcomes after same-day CAS plus 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 plus CABG, advised the investigators.
As summarized in EJVES, the investigators found that the 30-day death/stroke rate was 7.9% (95% confidence interval [CI], 6.9–9.2), and the death/stroke/myocardial infarction (MI) rate was 8.8% (95% CI, 7.3–10.5). Staged CAS plus CABG was associated with 30-day death/stroke rate of 8.5% (95% CI, 7.3–9.7) compared with 5.9% (95% CI, 4–8.5) after same-day procedures.
Outcomes after CAS plus CABG in neurologically symptomatic patients were poorer, with procedural stroke rates of 15%.
Additionally, there were five antiplatelet (APRx) strategies: (1) no APRx (death/stroke/MI, 4.2%; no data on bleeding complications); (2) single APRx before CAS and CABG, then dual APRx after CABG (death/stroke/MI, 6.7%; 7.3% bleeding complications); (3) dual APRx pre-CAS down to one APRx pre-CABG (death/stroke/MI, 10.1%; 2.8% bleeding complications); (4) dual APRx pre-CAS, both stopped pre-CABG (death/stroke/MI, 14.4%); and (5) dual APRx pre-CAS and continued through CABG (death/stroke/MI, 16%). There were insufficient data on bleeding complications in the last two strategies, noted the study investigators in EJVES.