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

Abstract

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.