Concurrent artery surgery increases stroke risk

Patients undergoing simultaneous carotid endarterectomy and coronary artery bypass graft surgeries may face a higher risk of stroke, according to a study published in Neurology.

The findings underscored the mounting prominence of minimally invasive image-guided therapies.

Severe vascular disease, among other factors, could account for a physician's decision to choose the combined procedures. Increasingly, patients undergo dual surgery hoping to reduce their risk of stroke or dying. Canadian investigators have found indications, however, that this practice could actually increase that risk instead.

Dr. Michael D. Hill and colleagues at the University of Calgary in Alberta reviewed the cases of 131,762 patients who underwent a coronary artery bypass graft (CABG) between 1992 and 2001. Among them, 669 underwent carotid endarterectomy (CEA) at the same time. The stroke and death rate in the combined group exceeded nearly threefold that of the CABG patients alone.

Actual benefits to patients from the combined CEA-CABG are not yet clear. Randomized trials are needed to assert the appropriateness of combining these procedures, Hill said.

Outcomes of the recent Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) Trial have validated carotid endovascular treatment as a preoperative alternative to endarterectomy for patients who need to undergo coronary surgery, according to Dr. Patrick Pullicino, a professor of neurology and neurosciences at the University of Medicine and Dentistry of New Jersey.

Angioplasty and stenting could be performed with a low combined stroke and death rate in high-risk patients with carotid stenosis, he said.

Pre-CABG carotid angioplasty with or without stenting has replaced endarterectomy at several centers in the U.S. as a direct result of the SAPPHIRE study. Surgeons who choose to perform CEA-CABG now face the burden of showing that the combined procedure can be performed with acceptable risks, Pullicino said.

For more information from the Diagnostic Imaging archives:

Carotid artery stenting takes off amid government limitations

Carotid stenting challenges endarterectomy in trials

Support for carotid stenting gathers momentum

Diffusion-weighted MR successfully monitors carotid stenting