Features December 2013 Issue

Study Reveals Lowest Risk Treatment For Severe Carotid, Coronary Disease

Cleveland Clinic researcher determines that carotid artery stenting, followed by open-heart surgery may be best for patients with severe combined conditions.

The combination of severe carotid artery disease and coronary artery disease (CAD) is usually treated by one of three approaches, but a Cleveland Clinic study found that patients who underwent stenting of the carotid artery followed by open-heart surgery experienced the best outcomes. That approach was shown to present fewer risks than the combination of carotid endarterectomy and open heart surgery—either done at the same time as the endarterectomy or a few weeks later. Endartectomy is a surgical procedure in which a blocked carotid artery is opened and the plaque in the artery is removed.

Ultrasound image: Nevit Dilmen found at Wikimedia commons

Ultrsound shows carotid artery stenosis of less than 70 percent, which means it may need to be treated with surgery or stenting, and no longer just drugs.

The study was led by Mehdi H. Shishehbor, DO, MPH, PhD, Director of Endovascular Services in the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic. He found that during the first year, patients who underwent carotid stenting followed later by open heart surgery had about the same reduced risk of death, stroke or heart attack as patients who had a procedure that combined an endarterectomy with open heart surgery. But after a year, the risk of serious events was much lower in the group of patients who underwenting stenting and surgery, compared with those who had an endarterectomy and heart surgery in one procedure or in a staged approach, which delayed heart surgery for a period of weeks after the carotid artery surgery.

“Our study shows that carotid artery 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,” Dr. Shishehbor says.

Coronary artery blockage
If you have blockage in one blood vessel, such as a carotid artery, it’s likely that you have plaque buildup in other arteries, too. But when you have narrowing in your coronary arties (those that supply blood to the heart muscle) and the carotid arteries (those that run up both sides of your neck and carry blood to the brain), the risk of heart attack and stroke is raised significantly. And when the blockages are severe and medication therapy and lifestyle changes aren’t improving your health, interventions at both locations are often necessary.

“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,” Dr. Shishehbor says.

Carotid artery stenting requires a catheter to place a stent at the site of blockage in the affected artery.

Blocked coronary arteries can sometimes be treated with stents, but in severe cases, bypass surgery is required.

Treating carotid artery disease
Significant blockage in a carotid artery is usually treated with an endarterectomy or with a stent that is put in place with a catheter. Both procedures have been proven safe in clinical trials, and the decision to perform surgery to remove plaque from the carotid artery or use a stent to open up a narrowed artery sometimes comes down to the actual location of the blockage or the age of the patient.

The option to put in stents has been available to doctors for a much shorter time than endarterectomy, so researchers are still gathering data on the long-term benefits of stenting. But as more evidence comes in, it appears that stenting is just as safe for many patients as surgery.

However, only three percent of patients with the combination of severe carotid artery and coronary artery disease are treated with stents and then open-heart surgery.
“As a result of this work, we are making changes to the way we approach patients with severe carotid artery and coronary artery disease at Cleveland Clinic,” Dr. Shishehbor says. “We are collaborating across disciplines to identify the lowest risk for each patient.”

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