Key result
Untreated severe carotid artery stenosis at the time of CABG was associated with a 3-fold higher perioperative ischemic stroke rate and lower 1- and 5-year survival.
Why the study?
Does untreated severe carotid artery stenosis at the time of CABG increase the risk of perioperative stroke and mortality?
Does untreated severe carotid artery stenosis at the time of CABG increase the risk of perioperative stroke and mortality?
Untreated severe carotid artery stenosis at the time of CABG is associated with higher perioperative stroke rates and lower long-term survival, though the strokes are often not anatomically related to the specific stenosis.
Central MessageUntreated severe carotid stenosis at the time of coronary surgery yields high perioperative stroke rate and lower 5-year survival. Perioperative stroke is unrelated to a carotid stenosis in 60%.See Article page 182. Untreated severe carotid stenosis at the time of coronary surgery yields high perioperative stroke rate and lower 5-year survival. Perioperative stroke is unrelated to a carotid stenosis in 60%. See Article page 182. Stroke is a major complication after cardiac surgery with or without extracorporeal circulation1Lorusso R. Moscarelli M. Di Franco A. Grazioli V. Nicolini F. Gherli T. et al.Association between coronary artery bypass surgical techniques and postoperative stroke.J Am Heart Assoc. 2019; 8: e013650Crossref PubMed Scopus (5) Google Scholar and percutaneous coronary intervention.2Sawano M. Kohsaka S. Ishii H. Numasawa Y. Yamaji K. Inohara T. et al.One-year outcome after percutaneous coronary intervention for acute coronary syndrome—an analysis of 20,042 patients from a Japanese nationwide registry.Circ J. June 24, 2021; ([Epub ahead of print])Crossref Scopus (1) Google Scholar Ischemic stroke is challenging because its pathophysiology is multifactorial and may develop at any time during and after cardiac operations. Usually, intraoperative and immediate postoperative stroke are not related to an individual risk factor like carotid disease. With due controversy, perfusion pressure,3Wiberg S. Holmgaard F. Blennow K. Nilsson J.C. Kjaergaard J. Wanscher M. Associations between mean arterial pressure during cardiopulmonary bypass and biomarkers of cerebral injury in patients undergoing cardiac surgery: secondary results from a randomized controlled trial.Interact Cardiovasc Thorac Surg. 2021; 32: 229-235Crossref PubMed Scopus (2) Google Scholar preoperative atrial fibrillation,4Hornero F. Martin E. Paredes F. Gil O. Cánovas S. García R. et al.Stroke after coronary artery bypass grafting: preoperative predictive accuracies of CHADS2 and CHA2DS2VASc stroke risk stratification schemes.J Thorac Cardiovasc Surg. 2012; 144: 1428-1435Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar aortic atheroma,5Asenbaum U. Nolz R. Puchner S.B. Schoster T. Baumann L. Furtner J. et al.Coronary artery bypass grafting and perioperative stroke: imaging of atherosclerotic plaques in the descending aorta with ungated high-pitch CT-angiography.Sci Rep. 2020; 10: 13909Crossref PubMed Scopus (1) Google Scholar combined intracardiac operations,6Schmitz C. Binder K. Bonatti J.O. van Boven W.J. Glauber M. Mestres C.A. et al.Intra-aortic filtration in cardiac surgery: an effective method to reduce neurologic injury in high-risk patients.Innovations (Phila). 2009; 4: 13-19Crossref PubMed Google Scholar and others may have an influence on stroke and outcomes. The landmark contribution of Roach and colleagues7Roach G.W. Kanchuger M. Mangano C.M. Newman M. Nussmeier N. Wolman R. et al.Adverse cerebral outcomes after coronary bypass surgery. Multicenter study of perioperative ischemia research group and the ischemia research and education foundation investigators.N Engl J Med. 1996; 335: 1857-1863Crossref PubMed Scopus (1618) Google Scholar determined the incidence of stroke after coronary artery bypass graft (CABG) surgery and identified independent predictors of cerebral outcomes. There was an estimated 3.1% incidence of type I focal adverse cerebral outcomes with influence on mortality and disability. Twenty-five years later, premises of that study, risk factors, and ultimately outcomes are similar. CABG is the most common operation in cardiac surgery even today with a risk of perioperative stroke of 1.3% to 1.4% or higher depending on statistics,8Fernandez F.G. Shahian D.M. Kormos R. Jacobs J.P. D'Agostino R.S. Mayer Jr., J.E. et al.The Society of Thoracic Surgeons national database 2019 annual report.Ann Thorac Surg. 2019; 108: 1625-1632Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar,9Roy P. Brahme I. Reddy R.P. Wechsler L. Gleason T. Thirumala P.D. Meta-analysis of perioperative stroke and mortality in CABG patients with carotid stenosis.Neurologist. 2020; 25: 113-116Crossref PubMed Scopus (0) Google Scholar the main problem being prevention. The value of preoperative imaging of the neck vessels and the brain has been studied in patients with multiple atheroma.10Ali I. Shokri H. Abd Al Jawad M. Assessment of carotid artery stenosis and lower limb peripheral ischemia before coronary artery bypass grafting operations: a non-randomized clinical trial.J Cardiothorac Surg. 2020; 15: 283Crossref PubMed Scopus (0) Google Scholar Hess and colleagues11Hess N.R. Kilic A. Serna-Gallegos D. Navid F. Ferdinand F.D. Wang Y. et al.Effect of untreated carotid artery stenosis at time of isolated coronary artery bypass grafting.J Thorac Cardiovasc Surg Open. 2021; 7: 182-190Google Scholar retrospectively investigated the prevalence of concurrent severe carotid artery stenosis (sCAS) at the time of CABG and its influence on perioperative and follow-up stroke. Stratification was based on ≥80% stenosis in at least 1 carotid artery evaluated with ultrasonography. Authors enrolled 5475 patients, 8.4% with and 91.6% without sCAS. Perioperative ischemic stroke rate was 3 times higher in sCAS, but only in 40% of cases could be anatomically related to the carotid stenosis detected. One- and 5-year survivals were lower in patients with sCAS. In multivariable analysis, sCAS was associated with increased risk-adjusted hazards for mortality and stroke, and the strongest risk-adjusted predictor for stroke was a prior history of stroke. A couple of important facts have been identified. The first is the much higher perioperative stroke rate in patients with untreated sCAS, although in less than one-half of patients a specific carotid stenosis might have been related to the event. Second, the 5-year survival was also lower in the sCAS group, with previous cerebrovascular accidents playing a role. Authors confirmed then that the structural and temporal relationships between coronary disease requiring CABG, sCAS and stroke, are quite complex and, after many years of multiple preventing strategies,12Gaudino M. Benesch C. Bakaeen F. DeAnda A. Fremes S.E. Glance L. et al.American Heart Association Council on Cardiovascular Surgery and Anesthesia; Stroke Council; and Council on Cardiovascular and Stroke NursingConsiderations for reduction of risk of perioperative stroke in adult patients undergoing cardiac and thoracic aortic operations: a scientific statement from the American Heart Association.Circulation. 2020; 142: e193-e209Crossref PubMed Scopus (11) Google Scholar we still have questions to answer. With the understanding of the important intrinsic limitations of the study, such as being retrospective, the degree of carotid stenosis chosen or lack of information about the actual strategy for CABG (circulatory support and graft selection), the information produced by the authors challenges again which is the best preoperative surveillance for neck atherosclerosis in patients undergoing CABG. Patients in the sCAS group were older, were more frequently women and had a higher prevalence of chronic obstructive pulmonary disease, heart failure, and peripheral arterial disease. Moreover, with only 40% of the perioperative strokes related to a given carotid location, the data shown herein may challenge not only whether or not pre-CABG carotid revascularization may be beneficial, but also whether or not routine carotid ultrasound workup should be performed in the absence of symptoms. The topic is still open for discussion. Effect of untreated carotid artery stenosis at the time of isolated coronary artery bypass graftingJTCVS OpenVol. 7PreviewSevere carotid artery stenosis (sCAS) is frequently discovered at the time of evaluation for coronary arterial revascularization. However, there has been controversy regarding the optimal management of sCAS. This study evaluated the potential effects of untreated sCAS at time of coronary artery bypass grafting (CABG) in contemporary practice. Full-Text PDF Open Access
No takes yet. Share an insight, caveat, or question.
Mestres et al. (2021) conducted an editorial in Coronary artery disease requiring CABG (n=5,475). Untreated severe carotid artery stenosis (sCAS) vs. No severe carotid artery stenosis was evaluated on Perioperative ischemic stroke and mortality. Untreated severe carotid artery stenosis at the time of CABG was associated with a 3-fold higher perioperative ischemic stroke rate and lower 1- and 5-year survival.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: