Synchronous versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid artery stenosis: A systematic review and meta-analysis

Background: Coronary artery disease requiring coronary artery bypass graft (CABG) frequently coexists with critical carotid stenosis. The most optimized strategy for treating concomitant carotid and coronary artery disease remains debatable. Objective: The aim of this meta-analysis was to compare synchronous CAS and CABG versus staged CAS and CABG for patients with concomitant coronary artery disease and carotid artery stenosis in terms of peri-operative (30-day) and long-term clinical outcomes. Methods: This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane database until December 2019. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess heterogeneity. Results: Four studies comprising 357 patients were included in this meta-analysis. Patients who were treated with the synchronous approach had a statistically significant higher risk for peri-operative stoke (OR: 3.71; 95% CI: 1.00–13.69; I2 = 0%) compared tο the staged group. Peri-operative mortality (OR: 4.50; 95% CI: 0.88–23.01; I2 = 0%), myocardial infarction (MI) (OR: 1.54; 95% CI: 0.18– 13.09; I2 = 0%), postoperative bleeding (OR: 0.27;95% CI: 0.02–3.12; I2 = 0%), transient ischemic attacks (TIA) (OR: 0.60; 95% CI: 0.04– 9.20; I2 = 0.0%), acute kidney injury (AKI) (OR: 0.34; 95% CI: 0.03–4.03; I2 = 0.0%) and atrial fibrillation rates (OR:0.27; 95% CI: 0.02–3.12; I2 = 0.0%) were similar between the two groups. Synchronous CAS-CABG and staged CAS followed by CABG were associated with similar rates of late mortality (OR: 3.75; 95% CI: 0.50–27.94; I2 = 0.0%), MI (OR: 0.33; 95% CI: 0.01–12.03; I2 = 0.0%) and stroke (OR:3.58; 95% CI:0.84–15.20; I2 = 0.0%) after a mean follow-up of 47 months. Conclusion: The simultaneous approach was associated with an increased risk of 30-day stroke compared to staged CAS and CABG. However, no statistically significant difference was found in long-term results of mortality, MI and stroke between the two approaches. Future studies are warranted to validate our results. © The Author(s) 2020

Synchronous Carotid Endarterectomy and Coronary Artery Bypass Graft versus Staged Carotid Artery Stenting and Coronary Artery Bypass Graft for Patients with Concomitant Severe Coronary and Carotid Stenosis: A Systematic Review and Meta-analysis

Background: Owing to the systemic nature of atherosclerosis, medium and large arteries at different sites are commonly simultaneously affected. As a result, severe coronary artery disease (CAD) requiring coronary artery bypass graft (CABG) frequently coexists with significant carotid stenosis that warrants revascularization. The aim of this study was to compare synchronous carotid endarterectomy (CEA) and CABG vs. staged carotid artery stenting (CAS) and CABG for patients with concomitant CAD and carotid artery stenosis in terms of perioperative (30-day) outcomes. Methods: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Eligible studies were identified through a search of PubMed, Scopus, and Cochrane until July 2018. A meta-analysis was conducted with the use of a random-effects model. The I-square statistic was used to assess heterogeneity. Results: Five studies comprising 16,712 patients were included in this meta-analysis. Perioperative stroke (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.43–1.64; I2 = 39.1%), transient ischemic attack (TIA; OR: 0.32; 95% CI: 0.04–2.67; I2 = 27.6%), and myocardial infarction (MI) rates (OR: 0.56; 95% CI: 0.08–3.85; I2 = 68.9%) were similar between the two groups. However, patients who underwent simultaneous CEA and CABG were at a statistically significant higher risk for perioperative mortality (OR: 1.80; 95% CI: 1.05–3.06; I2 = 0.0%). Conclusions: The current meta-analysis did not detect statistically significant differences in the rates of perioperative stroke, TIA, and MI between the groups. However, patients in the simultaneous CEA and CABG group had a significantly higher risk of 30-day mortality. Future randomized trials or prospective cohorts are needed to validate our results. © 2019 Elsevier Inc