Trattamento del paziente con stenosi coronarica e carotidea Fabrizio Tomai, MD, FACC, FESC Dept. of Cardiovasc. Sciences Interventional Cardiology Unit European & Aurelia Hospitals Rome
35 30 25 Combined Carotid and Coronary Artery Disease Percent 20 15 10 5 0 Prevalence of Carotid Artery Disease in CAD Patients Prevalence of Coronary Artery Disease in Carotid Patients Huh et al. Curr Op Cardiol 2003
Prevalence of CAD and long-term prognosis in patients undergoing carotid artery stenting 30 25 20 15 10 5 0 CAD prevalence: 69% (378/549 pts undergoing CAS) 18 p<0.00001 28.3 16 p<0.001 p<0.01 MACE 14 12 13.0 10 10.5 8 6 7.6 7.6 4 6.4 2 2.3 0 No-CAD CAD Cardiac Death All death No CAD CAD without significant stenosis CAD with significant stenosis Hofmann R et al.annals of Medicine 2006 16.1
Prevalence of CAD and long-term prognosis in patients undergoing carotid artery stenting 30 25 20 15 10 5 0 In the longer term, outcomes in pts undergoing CAS depend on concomitant CAD rather than neurological events, cardiac mortality and even allcad causeprevalence: mortality depending 69% (378/549 on a significant pts undergoing coronary CAS) artery stenosis 18 p<0.00001 28.3 16 p<0.001 p<0.01 MACE 14 12 13.0 10 10.5 8 6 7.6 7.6 4 6.4 2 2.3 0 No-CAD CAD Cardiac Death All death No CAD CAD without significant stenosis CAD with significant stenosis Hofmann R et al.annals of Medicine 2006 16.1
Prognostic value of carotid plaque in CAD patients Event-free survival (%) 100 90 80 70 60 50 0 X 2 =11.4; p=0.01 0 6 12 18 24 Follow up (months) Simple coronary and soft carotid plaques group (n=31) Simple coronary and hard carotid plaques group (n=50) Complex coronary and soft carotid plaques group (n=14) Complex coronary and hard carotid plaques group (n=49) Komorovsky et al. Am J Cardiol 2005
Therapeutic Strategies in Patients with Combined Coronary and Carotid Artery Disease Staged Strategy 1. CEA > CABG 2. CABG > CEA 3. CEA > PCI 4. CABG > CAS 5. CAS > CABG 6. PCI > CEA 7. CAS > PCI 8. PCI > CAS Surgical Hybrid Endovascular Revascularization PCI vs CABG & CAS vs CEA Simultaneous Strategy 9. CEA & CABG 10. CAS & PCI (or PCI & CAS) 11. Hybrid (CAS & CABG) Medical treatment Tomai F. 2008
Surgical approach in patients with combined coronary and carotid artery disease 12 10 8 6 30 day death/any any stroke/myocardial infarction 11.5% 10.2% 7.3% 4 2 Synchronous CEA + CABG Staged CEA > CABG Reverse staged CABG > CEA Naylor et al, EJVES 2003 (Meta-analysis of 10 studies)
Surgical approach in patients with combined coronary and carotid artery disease Variable N patients (%) Death 19 (6) Neurological complications Transiet Ischaemic attack 6 (2) Reversible neurological deficit 5 (1.5) Permanent stroke 12 (4) Cardiac complications Perioperative outcome (MACCE: 12%) Myocardial Infarction 7 (2) Arrhytmia 83 (27) Transient atrio-ventricular bloc 9 (3) Event 5 and 10 yrs late actuarial cardiac and neurological event free rates 5-yrs freedom (%) 10-yrs freedom (%) Death 79.1±2.5 50.0±4.2 Myocardial infarction 92.3±1.8 84.5±2.3 Percutaneous coronary intervention Reoperative coronary grafting 99.4±0.9 95.2±2.1 99.1±0.8 97.8±1.4 Total stroke 98.2±1.8 93.4±2.4 Ipsilateral stroke 99.4±0.9 95.5±2.6 All events 77.8±3.6 48.1±5.1 311 consecutive patients having concurrent CEA and CABG from 1989 to 2002 Kolh PH et al Eur Heart J 2006
Surgical approach in patients with combined coronary and carotid artery disease 30-day outcomes in 74 consecutive pts undergoing elective synchronous CEA and off-pump CABG (MACCE: 7.9%) 6 5 5.2 Events (%) 4 3 2 2.7 4.0 1 0 Death Perioperative MI Stroke Renal Failure Borioni R et al, 2010 (submitted)
Hybrid approach (CAS-CABG) CABG) in patients with combined coronary and carotid artery disease Death/Stroke/MI Events Pts Risk 95%CI Mendiz 4/30 13.3 3.3-26.7 Ziada 6/56 10.7 3.6-19.6 Versaci 3/37 8.1 0.0-18.9 Kovacic 2/20 10.0 0.0-25.0 Kramer 0/37 0.0 0.0-7.8 Gross 10/85 11.8 5.9-18.8 Van der Heyden 31/356 8.7 5.9-11.8 Abbasi 5/28 17.9 3.6-32.1 Total 61/649 9.4 7.0-11.8 30 day outcomes following staged Carotid Artery Stenting and Coronary Bypass: a meta-analysis 0 2 4 6 8 10 12 14 16 18 20 87% neurologically asymptomatic % Risk (95% CI) Naylor AR et al Eur J Vasc Endovasc Surg. 2009
Hybrid approach (PCI-CEA) CEA) in patients with combined coronary and carotid artery disease Staged Hybrid (PCI-CEA) CEA) Strategy Age <75 yrs vs > 75 yrs Male vs Female Hyperlipidemia vs none Diabetes vs none Hypertension vs none Lower Limb Occlusive Disease vs none Smoker vs non-smoker Coronary angiography vs none OR (95% CI) 0.98 (0.92-1.04) 0.70 (0.24-2.08) 1.00 (0.30-3.35) 2.44 (0.8-7.42) 1.23 (0.32-4.69) 3.25 (0.79-13.2) 2.74 (0.89-8.36) 0.22 (0.06-0.81) Systematic preoperative coronary angiography, possibly followed by PCI, significantly reduces the incidence of postoperative myocardial events after CEA in patients without clinical evidence of CAD. 0.01 0.5 1 2 3 4 Pts were operated on double antiplatelet therapy Illuminati G et al. Eur J Vasc Endovasc Surg 2010
Endovascular approach in patients with combined coronary and carotid artery disease Simultaneous Strategy Male, 82 yrs, CVAs, unstable angina, severe pulmonary disease, renal failure Tomai et al, Ital Heart J 2003
Endovascular approach in patients with combined coronary and carotid artery disease 30 day death/any any stroke/myocardial infarction 20 16 12 8 4 0 * 2 Minor strokes 10 % * Simultaneous PCI + CAS 0 % Staged PCI > CAS Al-Mubarak et al, Am J Cardiol 1999
Assessment of clinical outcome after combined revascularization of pluri-vascular atherosclerosis The Finalized Research In ENDovascular Strategies Study Group (FRIENDS) Fausto Castriota * Bernhard Reimers ** Flavio Ribichini *** Paolo Russo **** Fabrizio Tomai ***** * Cardiovascular Unit, Villa Maria Cecilia Hospital, Cotignola ** Division of Cardiology, Ospedale Civile di Mirano, Mirano *** Dept. of Biomedical Sciences and Surgery, University of Verona **** Villa Maria Pia Hospital, Torino ***** Dept. of Cardiovascular Sciences, European Hospital, Roma
Combined Carotid and Coronary Artery Disease
Endovascular, Surgical or Hybrid Revascularization in pts with Combined Carotid and Coronary Artery Disease The Finalized Research In ENDovascular Strategies Study Group (FRIENDS) Primary endpoint: MACCE at 30 days Secondary endpoint: MACCE, major bleeding, AKI in-hospital 10 % 9 8 7 6 5 4 3 2 1 0 30 p=0.01 % p<0.001 9.2 25 25.5 20 15 4.8 10 10.1 2.4 5 6.5 0 Surgical Endovascular Hybrid Surgical Endovascular Hybrid (185 pts) (378 pts) (89 pts) (185 pts) (378 pts) (89 pts) Ribichini F and Tomai F for the FRIENDS Study Group. EuroIntervention 2010
Endovascular Revascularization in pts with Combined Carotid and Coronary Artery Disease The Finalized Research In ENDovascular Strategies Study Group (FRIENDS) Primary endpoint: Death, MI and stroke at 30 days Secondary endpoint: Death, MI and stroke at 2 years 3 8 % % 7 2,5 2.5 6 2 5 1,5 1 0,5 0 30-D MACCE: 4.2% 2-Y MACCE:11.3% Jan 2006-Apr 2010 N= 239 0.4 1.3 Death MI Stroke 4 3 2 1 0 4.2 2.9 4.2 Death MI Stroke Tomai F. et al for the FRIENDS Study Group. 2010 (submitted)
Female,, 74 yrs old recent TIA (10 days) High risk carotid plaque Chronic stable angina One-vessel disease Normal LV function Carotid first!
Male, 68 yrs old Previous stroke (5 months) Low risk carotid plaque NSTEMI Previous CABG Multi-vessel disease Poor LV function Coronary first!
Male, 74 yrs old, NSTEMI, Leriche Syndrome, left ICA 100% Staged strategy: PCI first
Female,, 79 yrs old, TIA, Aortic valve prostesis,, by-pass disease Staged strategy: CAS first
Male, 82 yrs old, unstable angina, TIAs, severe pulmonary disease, renal failure Simultaneous strategy
Therapeutic Strategies in Patients with Combined Coronary and Carotid Artery Disease Endovascular, Surgical or Hybrid Approach? 1. No sufficient data at the present time; however, the strategy is often dependent on the specific clinical characteristics of the patient 2. Risk stratification 3. Anatomical (endovascular vs. surgical) feasibility 4. Patient preference 5. Team experience 6. The endovascular treatment, being less invasive, may be particularly suited to these fragile and complex patients
ESC Guidelines: latest news European Heart Journal 2010; August 29 doi:10.1093/eurheartj/ online first ESC GUIDELINES ESC / EACTS Guidelines on Myocardial Revascularisation The Task Force on Myocardial Revascularisation of the European Society of Cardiology (ESC) and the European Association of Cardio-Thoracic Surgery (EACTS) Endorsed by European Association for Percutaneous Cardiovascular Interventions (EAPCI) New Myocardial Revascularization Guidelines have a dedicated chapter for patients needing myocardial revascularization and having concomitant carotid obstructive disease.
ESC Guidelines: latest news European Heart Journal 2010; August 29 doi:10.1093/eurheartj/ online first ESC GUIDELINES ESC / EACTS Guidelines on Myocardial Revascularisation