Coexisting Coronary and Carotid Artery Disease – Which Technique and in Which Order? Case Report and Review of Literature

Abstract

Coexisting carotid artery stenosis and coronary artery disease is common and there is currently no consensus in treatment guidelines on the timing, sequence and methods of revascularization. We report a case of a patient with symptomatic triple vessel coronary artery disease as well as asymptomatic severe right internal carotid artery stenosis. Our patient underwent myocardial revascularization first, because she presented with unstable angina and was asymptomatic neurologically. This article summarizes current literature about the approach to carotid and coronary artery revascularization and addresses the decision-making process regarding the timing and sequence of revascularization.

Survival and Prognostic Factors After Carotid Artery Stenting in Patients with Concomitant Coronary Disease

“…The results, however, are very confusingly different: The risk of stroke/death in simultaneous CEA and CABG is highest and lowest in a stepwise approach [45], [46]; in a registry of 27,084 patients in the CAS-CABG versus CEA-CABG strategies, the incidence of postoperative stroke was 2.4% versus 3.9% (p < 0.001) and of stroke/death 6.9% versus 8.6% (p = 0.1) [47]; according to Versaci et al CAS immediately before CABG gives promising results with a low incidence of death/stroke [48]; 132 patients treated with CAS and CABG on the same day had an in-hospital stroke rate of 0.75% and a 5-and 10-year period free from neurological events of 95% and 85%, respectively; analysis in 350 patients with staged CEA, followed up to 90 days after CABG showed the worst results for MI between revascularization stages [49]. In recent studies by the teams of Sulženko [19] (2019), Kumar et al [50] (2020), Shen et al [51], Manthey et al [52] (2020), Tzoumas et al [53] (2020) results and opinions are mixed, but the need to utilize the effect of CEA/CAS in underlying coronary stenosis by revascularization of both vascular areas is a common opinion. Addressing this problem, our results in high-risk patients show that stepwise PCI before CAS yields significantly better MS than revascularization after CAS (χ 2 = 5.306, p = 0.018).…”

Revascularization methods in patients with carotid stenosis and concomitant coronary heart disease

“…[47] In recent surveys by the teams of Kumar S (2020), Manthey S (2020), and Tzoumas A (2020), the results and opinions are similar -a comprehensive revascularization strategy is required in the presence of underlying significant coronary heart disease. [48][49][50]…”

Hybrid revascularization: stenting of left internal carotid artery after restenosis, combined with left anterior descending artery stenting and right carotid endarterectomy

“…Доказана важность гибридной хирургии в лечении больных с симультанным атеросклеротическим поражением ВСА и коронарных артерий. поражения ПНА нестабильная гемодинамика может стать одним из ключевых факторов ишемического повреждения миокарда [1,[3][4][5]. В рамках настоящего гибридного подхода ЧКВ не только стало одним из главных звеньев цепочки вмешательств, но и было выполнено на первом этапе.…”

“…Сочетанное поражение каротидных и коронарных артерий всегда вызывало особый интерес сосудистых хирургов, нейрохирургов, кардиологов, неврологов ввиду отсутствия единого подхода к выбору стратегии реваскуляризации [1][2][3]. С одной стороны, первоэтапное вмешательство на внутренней сонной артерии (ВСА) повышает риски развития инфаркта миокарда [4,5]. Однако при обратном порядке реконструкций возрастает вероятность острого нарушения мозгового кровообращения [6,7].…”