There may be a better first option for treating patients with severely blocked arteries in the heart and neck.
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A Cleveland Clinic study finds that the little-used technique — carotid stenting followed by open heart surgery — results in the best outcomes among the most common treatments for severe carotid and coronary artery disease.
Typically surgeons cut into the neck, scrape out plaque buildup and then perform open-heart bypass surgery either at the same time or a few weeks later.
But the study found that patients who received stents in their neck (carotid) arteries and then had open heart surgery a few weeks later had much lower chances of having heart attack, stroke or dying in following years than with other procedures.
Technique should be first-line strategy
Mehdi H. Shishehbor, DO, MPH, PhD, who led the study, says the technique should be the first-line strategy for treating patients with severe carotid and coronary disease, if the three- to four-week wait between procedures are clinically acceptable.
“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,” says Dr. Shishehbor.
Stenting plus separate surgery gets best results
The study compared carotid stenting — an endovascular procedure in which a small metal mesh tube is placed in the carotid artery — followed by a separate open heart surgery to both staged and combined carotid endarterectomy, surgery that scrapes off the plaque in the carotid artery, and open heart surgery.
For patients with a severe blockage in the carotid artery in addition to coronary disease, physicians usually recommend treatment that includes a carotid endarterectomy, as well as open heart surgery for the coronary disease.
These treatments are sometimes done in stages, with the carotid surgery performed a few weeks before the coronary operation, or simultaneously during one procedure.
What the study found
The researchers 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 heart attack, stroke or dying than those who underwent an endarterectomy, whether it was performed separately from or combined with the open heart surgery.
Identifying the lowest risk treatment
Only 3 percent of U.S. patients with both severe carotid and coronary artery disease currently receive staged carotid stenting followed by open heart surgery. In the study, 31 percent of the subjects got this treatment.
“As a result of this work, we’re making changes to the way we approach patients with severe carotid and coronary artery disease,” says Dr. Shishehbor. “We are collaborating across disciplines to identify the lowest risk treatment option for each patient.”
The retrospective study was published in the Journal of the American College of Cardiology.