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INVITED COMMENTARY
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 101-102

On Bilateral Carotid Stenting by Prof. Ross Naylor: “More Questions Than Anwers”


Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, UK

Date of Web Publication31-Jul-2017

Correspondence Address:
A Ross Naylor
Department of Vascular Surgery, Leicester Royal Infirmary, Leicester
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_35_17

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How to cite this article:
Naylor A R. On Bilateral Carotid Stenting by Prof. Ross Naylor: “More Questions Than Anwers”. Indian J Vasc Endovasc Surg 2017;4:101-2

How to cite this URL:
Naylor A R. On Bilateral Carotid Stenting by Prof. Ross Naylor: “More Questions Than Anwers”. Indian J Vasc Endovasc Surg [serial online] 2017 [cited 2020 Jun 1];4:101-2. Available from: http://www.indjvascsurg.org/text.asp?2017/4/3/101/211911



In this issue of the Indian Journal of Vascular and Endovascular Surgery, Karanam et al. report the outcome of 33 patients who underwent simultaneous bilateral carotid artery stent (CAS) placement, 29 of whom then underwent coronary artery bypass grafting (CABG) within 3 weeks of the CAS procedures.[1] Aside from hemodynamic problems (four after the first CAS procedure and seven after the second), there were no perioperative strokes or deaths following the CAS or CABG interventions. The authors concluded that bilateral CAS was an option in “high-risk” patients before CABG, with the prospect of minimal morbidity and mortality.

This study is slightly unusual, in that all 33 patients had suffered either a transient ischemic attack (TIA) or stroke in the preceding 2 weeks (in the presence of bilateral carotid stenoses) and were then listed for CABG. No explanation was provided as to why these patients required a semi-urgent CABG in addition to treating their carotid lesions. In a recently published meta-analysis, involving 2727 patients who underwent “same day” or synchronous CAS + CABG, over 80% were asymptomatic and > 80% had a unilateral carotid stenosis.[2] In addition, 12 (36%) of the patients in the current study presented with bilateral TIAs/strokes. That, in itself, is very unusual compared to a typical Western carotid practice. In a 26-year career as a vascular surgeon with interest in carotid disease, I can only recall about three patients who presented with Neurologist verified, bilateral carotid territory symptoms. However, in patients who present with bilateral symptomatic carotid stenoses and who definitely need to undergo expedited CABG, bilateral synchronous CAS may be entirely appropriate in experienced hands. I would certainly not consider bilateral synchronous CEA + CABG in this type of patient as bilateral recurrent laryngeal or hypoglossal nerve palsies can be fatal.

That leaves the remaining 21 patients who presented with a unilateral, recently symptomatic stenosis in the presence of a contralateral asymptomatic stenosis, in whom Karanam et al. performed synchronous bilateral CAS procedures, rather than simply treating the symptomatic stenosis on its own. Their rationale was that this would otherwise have delayed treatment of the contralateral asymptomatic stenosis. In reality, this rationale for practice is somewhat speculative as there is little evidence that not revascularizing the contralateral asymptomatic stenosis before CABG (while treating the symptomatic carotid stenosis) increases the risk of post-CABG stroke in the hemisphere ipsilateral to the nonoperated asymptomatic stenosis.[3],[4] Most clinicians would usually advocate treating the asymptomatic stenosis at a later date (if necessary) when the patient had fully recovered from both the CAS and CABG procedures. This is partly because there is now increasing evidence that only a relative minority of asymptomatic patients require a carotid intervention,[5] while national audits report a 20–30% decline in absolute numbers of annual interventions in asymptomatic patients over recent years.[6],[7]

One other interesting observation to come from this study was the antiplatelet strategy adopted during the CAS and CABG procedures. Karanam et al. advocated stopping dual antiplatelet therapy (DAPT) 2 days before CABG, with it being restarted 2 days later. No explanation was provided in support of this strategy, despite the fact that the half-life of a platelet is about 10 days, i.e. 80% of the circulating platelets would still be blocked by the DAPT. Interestingly, the CAS + CABG meta-analysis suggested that “same-day” CAS + CABG could be undertaken (while on antiplatelet therapy), without incurring excess procedural risks.[1]

In summary, this study suggests that bilateral CAS is feasible in a small cohort of highly selected patients with bilateral symptomatic carotid disease, before CABG. However, I remain to be convinced that it is the preferred strategy in patients with a symptomatic carotid stenosis and an asymptomatic contralateral stenosis before CABG.



 
  References Top

1.
Karanam LSP, Baddam SR, Polavarapu A, Pamidimukkala V, Polavarapu R. Simultaneous bilateral carotid stenting in high risk patients: A single-center experience with review of literature. Indian J Vasc Endovasc Surg 2017;4:97-100.  Back to cited text no. 1
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2.
Paraskevas K, Batchelder A, Bown M, Naylor AR. An updated systematic review and meta-analysis of 30-day outcomes following staged carotid artery stenting and coronary bypass. Eur J Vasc Endovasc Surg 2017;53:309-19.  Back to cited text no. 2
    
3.
Naylor AR. Synchronous cardiac and carotid revascularisation: The devil is in the detail. Eur J Vasc Endovasc Surg 2010;40:303-8.  Back to cited text no. 3
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4.
Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: An updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2011;41:607-24.  Back to cited text no. 4
[PUBMED]    
5.
Naylor AR. Why is the management of asymptomatic carotid disease so controversial? Surgeon 2015;13:34-43.  Back to cited text no. 5
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6.
Kim LK, Yang DC, Swaminathan RV, Minutello RM, Okin PM, Lee MK, et al. Comparison of trends and outcomes of carotid artery stenting and endarterectomy in the United States, 2001 to 2010. Circ Cardiovasc Interv 2014;7:692-700.  Back to cited text no. 6
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7.
Hussain MA, Mamdani M, Tu JV, Saposnik G, Khoushhal Z, Aljabri B, et al. Impact of clinical trial results on the temporal trends of carotid endarterectomy and stenting from 2002 to 2014. Stroke 2016;47:2923-30.  Back to cited text no. 7
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