J Clin Neurol.  2015 Oct;11(4):364-371. 10.3988/jcn.2015.11.4.364.

Preoperative Coronary Stenosis Is a Determinant of Early Vascular Outcome after Carotid Endarterectomy

• Kim JH
• Heo SH
• Nam HJ
• Youn HC
• Kim EJ
• Lee JS
• Kim YS
• Kim HY
• Koh SH
• Chang DI

• KMID: 2179756
• DOI: http://doi.org/10.3988/jcn.2015.11.4.364

Abstract

BACKGROUND AND PURPOSE
The benefit of carotid endarterectomy (CEA) is directly influenced by the risk of perioperative adverse outcomes. However, patient-level risks and predictors including coronary stenosis are rarely evaluated, especially in Asian patients. The aim of this study was to determine the relationship between the vascular risk factors underlying CEA, including coronary stenosis, and postoperative outcome.
METHODS
One hundred and fifty-three consecutive CEAs from our hospital records were included in this analysis. All patients underwent coronary computed tomography angiography before CEA. Data were analyzed to determine the vascular outcomes in patients with mild-to-moderate vs. severe coronary stenosis and high vs. standard operative risk, based on the criteria for high operative risk defined in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial. The vascular outcome was defined as the occurrence of postoperative (< or =30 days) stroke, myocardial infarction (MI), or death.
RESULTS
An adverse vascular outcome occurred in 8 of the 153 CEAs, with 6 strokes, 2 MIs, and 3 deaths. The vascular outcome differed significantly between the groups with mild-to-moderate and severe coronary stenosis (p=0.024), but not between the high- and standard-operative-risk groups (stratified according to operative risk as defined in the SAPPHIRE trial). Multivariable analysis adjusting for potent predictors revealed that severe coronary stenosis (odds ratio, 6.87; 95% confidence interval, 1.20-39.22) was a significant predictor of the early vascular outcome.
CONCLUSIONS
Severe coronary stenosis was identified herein as an independent predictor of an adverse early vascular outcome.

Keyword

carotid endarterectomy; coronary artery disease; coronary angiography; risk assessment

MeSH Terms

Aluminum Oxide
Angiography
Angioplasty
Asian Continental Ancestry Group
Coronary Angiography
Coronary Artery Disease
Coronary Stenosis*
Endarterectomy
Endarterectomy, Carotid*
Hospital Records
Humans
Myocardial Infarction
Risk Assessment
Risk Factors
Stents
Stroke
Aluminum Oxide

Figure

• 

  Fig. 1 Preoperative coronary workups for all procedures (n=153). CAG: coronary angiography, CCTA: coronary computed tomography angiography, CEA: carotid endarterectomy, PCI: percutaneous coronary intervention.

Reference

1. Hong KS, Bang OY, Kang DW, Yu KH, Bae HJ, Lee JS, et al. Stroke statistics in Korea: part I. Epidemiology and risk factors: a report from the Korean Stroke Society and clinical research center for stroke. J Stroke. 2013; 15:2–20.

2. Jung KH, Lee SH, Kim BJ, Yu KH, Hong KS, Lee BC, et al. Secular trends in ischemic stroke characteristics in a rapidly developed country: results from the Korean Stroke Registry Study (secular trends in Korean stroke). Circ Cardiovasc Qual Outcomes. 2012; 5:327–334.

3. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004; 363:1491–1502.

4. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1998; 339:1415–1425.

5. Naylor AR. Time to rethink management strategies in asymptomatic carotid artery disease. Nat Rev Cardiol. 2011; 9:116–124.

6. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke. 2009; 40:e573–e583.

7. Musser DJ, Nicholas GG, Reed JF 3rd. Death and adverse cardiac events after carotid endarterectomy. J Vasc Surg. 1994; 19:615–622.

8. Halm EA, Tuhrim S, Wang JJ, Rockman C, Riles TS, Chassin MR. Risk factors for perioperative death and stroke after carotid endarterectomy: results of the new york carotid artery surgery study. Stroke. 2009; 40:221–229.

9. Bekelis K, Bakhoum SF, Desai A, Mackenzie TA, Goodney P, Labropoulos N. A risk factor-based predictive model of outcomes in carotid endarterectomy: the National Surgical Quality Improvement Program 2005-2010. Stroke. 2013; 44:1085–1090.

10. Heo SH, Cho CH, Kim HO, Jo YH, Yoon KS, Lee JH, et al. Plaque rupture is a determinant of vascular events in carotid artery atherosclerotic disease: involvement of matrix metalloproteinases 2 and 9. J Clin Neurol. 2011; 7:69–76.

11. Chimowitz MI, Mancini GB. Asymptomatic coronary artery disease in patients with stroke. Prevalence, prognosis, diagnosis, and treatment. Stroke. 1992; 23:433–436.

12. Craven TE, Ryu JE, Espeland MA, Kahl FR, McKinney WM, Toole JF, et al. Evaluation of the associations between carotid artery atherosclerosis and coronary artery stenosis. A case-control study. Circulation. 1990; 82:1230–1242.

13. Urbinati S, Di Pasquale G, Andreoli A, Lusa AM, Ruffini M, Lanzino G, et al. Frequency and prognostic significance of silent coronary artery disease in patients with cerebral ischemia undergoing carotid endarterectomy. Am J Cardiol. 1992; 69:1166–1170.

14. Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010; 363:11–23.

15. Cury RC, Ferencik M, Achenbach S, Pomerantsev E, Nieman K, Moselewski F, et al. Accuracy of 16-slice multi-detector CT to quantify the degree of coronary artery stenosis: assessment of cross-sectional and longitudinal vessel reconstructions. Eur J Radiol. 2006; 57:345–350.

16. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004; 351:1493–1501.

17. Duncan JM, Reul GJ, Ott DA, Kincade RC, Davis JW. Outcomes and risk factors in 1,609 carotid endarterectomies. Tex Heart Inst J. 2008; 35:104–110.

18. Illuminati G, Ricco JB, Greco C, Mangieri E, Calio' F, Ceccanei G, et al. Systematic preoperative coronary angiography and stenting improves postoperative results of carotid endarterectomy in patients with asymptomatic coronary artery disease: a randomised controlled trial. Eur J Vasc Endovasc Surg. 2010; 39:139–145.

19. Uno M, Ueda S, Shinno K, Nishi K, Nishitani K, Nagahiro S. Coronary artery stenosis evaluated by combined carotid and coronary angiography in patients undergoing carotid endarterectomy. Neurol Med Chir (Tokyo). 1999; 39:567–573. discussion 573-574

20. Stoner MC, Abbott WM, Wong DR, Hua HT, Lamuraglia GM, Kwolek CJ, et al. Defining the high-risk patient for carotid endarterectomy: an analysis of the prospective National Surgical Quality Improvement Program database. J Vasc Surg. 2006; 43:285–295. discussion 295-296

21. Hausleiter J, Meyer T, Hadamitzky M, Zankl M, Gerein P, Dörrler K, et al. Non-invasive coronary computed tomographic angiography for patients with suspected coronary artery disease: the Coronary Angiography by Computed Tomography with the Use of a Submillimeter resolution (CACTUS) trial. Eur Heart J. 2007; 28:3034–3041.

22. Joshi SB, Okabe T, Roswell RO, Weissman G, Lopez CF, Lindsay J, et al. Accuracy of computed tomographic angiography for stenosis quantification using quantitative coronary angiography or intravascular ultrasound as the gold standard. Am J Cardiol. 2009; 104:1047–1051.

23. Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008; 359:2324–2336.

24. Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008; 52:1724–1732.

25. Meijboom WB, Meijs MF, Schuijf JD, Cramer MJ, Mollet NR, van Mieghem CA, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008; 52:2135–2144.

26. Hulten EA, Carbonaro S, Petrillo SP, Mitchell JD, Villines TC. Prognostic value of cardiac computed tomography angiography: a systematic review and meta-analysis. J Am Coll Cardiol. 2011; 57:1237–1247.

27. Krupski WC. Myocardial revascularization before carotid endarterectomy. J Cardiovasc Surg (Torino). 2003; 44:371–382.

28. Jordan WD Jr, Alcocer F, Wirthlin DJ, Fisher WS, Warren JA, Mc-Dowell HA Jr, et al. High-risk carotid endarterectomy: challenges for carotid stent protocols. J Vasc Surg. 2002; 35:16–21. discussion 22

29. Mozes G, Sullivan TM, Torres-Russotto DR, Bower TC, Hoskin TL, Sampaio SM, et al. Carotid endarterectomy in SAPPHIRE-eligible high-risk patients: implications for selecting patients for carotid angioplasty and stenting. J Vasc Surg. 2004; 39:958–965. discussion 965-966

30. Gasparis AP, Ricotta L, Cuadra SA, Char DJ, Purtill WA, Van Bemmelen PS, et al. High-risk carotid endarterectomy: fact or fiction. J Vasc Surg. 2003; 37:40–46.

31. Cacoub PP, Abola MT, Baumgartner I, Bhatt DL, Creager MA, Liau CS, et al. Cardiovascular risk factor control and outcomes in peripheral artery disease patients in the Reduction of Atherothrombosis for Continued Health (REACH) Registry. Atherosclerosis. 2009; 204:e86–e92.

32. Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, Wallace MC, et al. The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke. 1999; 30:1751–1758.

33. SPACE Collaborative Group. Ringleb PA, Allenberg J, Brückmann H, Eckstein HH, Fraedrich G, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet. 2006; 368:1239–1247.

34. Young B, Moore WS, Robertson JT, Toole JF, Ernst CB, Cohen SN, et al. An analysis of perioperative surgical mortality and morbidity in the asymptomatic carotid atherosclerosis study. ACAS Investigators. Asymptomatic Carotid Atherosclerosis Study. Stroke. 1996; 27:2216–2224.

35. Kucey DS, Bowyer B, Iron K, Austin P, Anderson G, Tu JV. Determinants of outcome after carotid endarterectomy. J Vasc Surg. 1998; 28:1051–1058.

36. Sheikh K, Bullock C. Variation and changes in state-specific carotid endarterectomy and 30-day mortality rates, United States, 1991-2000. J Vasc Surg. 2003; 38:779–784.

37. Sprung J, Abdelmalak B, Gottlieb A, Mayhew C, Hammel J, Levy PJ, et al. Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery. Anesthesiology. 2000; 93:129–140.