Cleveland Clinic study finds lowest risk treatment for severe carotid and coronary disease

Of the three most common treatment approaches for patients with severe carotid and coronary artery disease, patients who underwent stenting of the carotid artery followed by open heart surgery had the best outcomes, according to a retrospective study from Cleveland Clinic published online today in the Journal of the American College of Cardiology.

01 aug 2013--The study compared carotid stenting followed by open heart surgery to both staged and combined carotid endarterectomy and open heart surgery.

For patients with a severe blockage in the carotid artery in addition to coronary disease, physicians commonly recommend a course of treatment that includes a carotid endarterectomy, a surgical procedure to remove the plaque buildup in the carotid artery, as well as open heart surgery for the coronary disease, according to the researchers. These treatments are sometimes done in stages, with the carotid surgery performed a few weeks before the coronary operation, or simultaneously during one procedure. More recently, the researchers write, a third alternative has come into play: carotid stenting, an endovascular procedure in which a scaffold is placed in the carotid artery, followed by a separate open heart surgery.

The researchers, led by Mehdi H. Shishehbor, D.O., M.P.H., Ph.D., Director of Endovascular Services in the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic, examined the short- and long-term outcomes of 350 patients who underwent a carotid revascularization procedure within 90 days of a planned open heart surgery at Cleveland Clinic between January 1997 and August 2009. The study population consisted primarily of patients who were found to have severe carotid artery disease as part of their evaluation prior to open heart surgery.

In the short term, patients who underwent carotid stenting or combined endarterectomy had a lower risk of death, stroke or heart attack than those who underwent a staged endarterectomy followed by a separate open heart surgery. After the first year, however, the researchers found that patients who received carotid stents had a significantly lower risk of serious events than those who underwent an endarterectomy, whether it was performed separately from, or combined with, the open heart surgery.

"Our study shows that carotid stenting followed by open heart surgery should be the first line strategy for treating patients with severe carotid and coronary disease, if the three- to four-week wait between procedures is clinically acceptable," said Shishehbor. "There has never been a randomized clinical trial to determine the best approach for these patients, but the evidence in this study may be enough to change practice."

At present in the United States, only 3 percent of patients with concomitant severe carotid and coronary artery disease receive staged carotid stenting followed by open heart surgery. In the study population, 31 percent of the subjects were treated in this manner.

"As a result of this work, we are making changes to the way we approach patients with severe carotid and coronary artery disease at Cleveland Clinic," said Shishehbor. "We are collaborating across disciplines to identify the lowest risk treatment option for each patient."

Provided by Cleveland Clinic

VAS-COG: Brain Effects of Carotid Disease Emerge in Middle Age

SAN ANTONIO, July 13 -- Years before carotid artery disease poses a stroke risk, arterial thickening and early-stage atherosclerosis may cause deterioration in cognitive performance.
Early carotid disease was associated with lower total cerebral brain volume (P=0.04 with >25% stenosis) and an increased prevalence of white matter hyperintensity (P=0.001 with >25% stenosis) on MRI, indicative of brain ischemia and aging, investigators reported at the International Society of Vascular Behavioral and Cognitive Disorders meeting here.
Thickening of the internal carotid artery had the greatest impact, however, with MRI evidence of aging and decreased performance on multiple measures of cognitive function, said Jose Rafael Romero, M.D., of the University of Kansas Medical Center in Kansas City.
"The associations varied according to the carotid arterial site where atherosclerosis was evaluated," he said.
Vascular risk factors are associated with carotid stenosis, carotid intima-media thickness (IMT), and MRI signs of brain ischemia and aging, specifically white matter hyperintensity and reduced brain volume. MRI evidence of ischemia and aging has been linked to an increased risk of cognitive impairment, dementia, and stroke.
The Framingham Offspring Study afforded an opportunity to study associations among vascular risk factors, carotid disease, and MRI evidence of brain ischemia and aging, said Dr. Romero.
In particular, the Framingham database allowed Dr. Romero and colleagues to examine the effect of site-specific differences in carotid atherosclerosis on MRI brain volume and cognitive performance.
Their study involved 2,236 men and women whose mean age was 58. The participants had had a carotid ultrasound during the 1995 through 1998 Framingham examination cycle and brain MRI and neuropsychological testing during the 1999-2001 cycle. All of the patients were free of stroke, dementia, and neurologic disease at the time of the MRI scan.
Carotid ultrasound was by a standard protocol that consisted of two images at the common carotid, bifurcation, and proximal internal carotid arteries. Intima-media thickness was measured at three sites in both carotid arteries, and maximal thickness was the measure used for analysis.
Total cerebral brain volume was assessed by quantitative MRI, read by a radiologist blinded to the clinical data. Large areas of white matter hyperintensity also were examined.
Five aspects of neuropsychological functioning were included in the study: verbal memory, visual memory, new learning, executive function, and non-memory.
Dr. Romero reported that 14.6% of study participants had carotid stenosis in excess of 25%, and 1.8% had stenosis in excess of 50%. Total cerebral brain volume (parenchymal volume divided by intracranial volume) averaged 78%, and 13% of participants had large white matter hyperintensity.
In a multivariate analysis adjusted for age, sex, and stroke risk factors, carotid stenosis greater than 25% had a significant association with large white matter hyperintensity (P=0.001) and lower total cerebral brain volume (P=0.04). Stenosis exceeding 50% was associated with white matter hyperintensity (P=0.03) and impaired executive function (P=0.03).
A greater intima-media thickness in the internal carotid artery predicted larger white matter hyperintensity (P=0.02), reduced brain volume (P=0.02), impaired verbal memory (P=0.05), and nonmemory cognitive function (P=0.004).
Intima-media thickness of the common carotid arteries did not correlate with any of the outcome parameters.
Reviewing limitations of the study, Dr. Romero noted that the population was predominantly white, and the study was a cross-sectional analysis. However, the large sample size and the community-based environment lent credence to the results, he said.
The study had no commercial support, and none of the investigators had disclosures related to the study. Primary source: International Society of Vascular Behavioral and Cognitive Disorders
Source reference: JR Romero et al. "Carotid atherosclerosis, MRI indices of brain ischemia and aging and cognitive impairment: the Framingham Study." Presented at the International Society of Vascular Behavioral and Cognitive Disorders meeting, July 11-14, San Antonio. Abstract. O-2.