Invited Commentary

Abstract

About 15 to 25 years ago when coronary artery bypass grafting (CABG) was more common, the approach of combined carotid endarterectomy (CE) plus CABG/open heart surgery (OHS) was a frequent operation, and many articles were published on the merits of the method, including some from our own institution. Last year, we published an article from our institution [1Shishehbor M.H. Venkatachalam S. Sun Z. et al.A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery.J Am Coll Cardiol. 2013; 62: 1948-1956Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar] comparing various strategies: (1) staged CE followed by CABG/OHS, (2) combined CE plus CABG/OHS, and (3) carotid stenting (CS) followed by staged CABG/OHS. We showed that CE-staged CABG/OHS had the highest risk of interval myocardial infarction, with no early difference in mortality or stroke between combined CE plus CABG/OHS and CS-staged CABG/OHS. We demonstrated, using late hazard analysis, that CS-staged CABG/OHS had the lowest risk of late events. The next logical step was combining CS plus CABG/OHS during the same operation because hybrid procedures have become common, including CABG/OHS plus coronary or carotid procedures. In this issue of The Annals of Thoracic Surgery, Chiariello and colleagues [2Chiariello L. Nardi P. Pellegrino A. et al.Simultaneous carotid artery stenting and heart surgery: expanded experience of hybrid surgical procedures.Ann Thorac Surg. 2015; 99: 1291-1297Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] have reported a series of 132 patients undergoing combined CS plus CABG/OHS with a low stroke rate of 0.75% (1 patient), and that result is considerably better than historical CE plus CABG/OHS reports. Given the declining rate of CABG and CE operations, it is unlikely that a randomized trial will be performed to study combined CE plus CABG/OHS versus combined CS plus CABG/OHS. This reported study, and undoubtedly those that follow, will support combined CS plus CABG/OHS as a reasonable alternative to staged CS and CABG/OHS when the latter is not feasible, eg, because of a pressing need for a shorter time interval between procedures. The important unanswered questions that remain are: Which patients need a hybrid procedure and what is the additional bleeding risk of this approach from dual-antiplatelet therapy in the immediate postoperative period? Simultaneous Carotid Artery Stenting and Heart Surgery: Expanded Experience of Hybrid Surgical ProceduresThe Annals of Thoracic SurgeryVol. 99Issue 4PreviewThe aim of this study was to evaluate 10-year results of same-day hybrid revascularization of concomitant carotid artery disease by stenting (CAS) and coronary artery disease by coronary artery bypass grafting (CABG), later also applied to patients requiring CAS and other than coronary open heart cardiac surgery. Full-Text PDF Simultaneous Carotid Artery Stenting and Heart Surgery: The Risk of BleedingThe Annals of Thoracic SurgeryVol. 100Issue 6PreviewWe read with great interest the Invited Commentary by Svensson and colleagues [1], which centered on the risk of bleeding after treatment of carotid artery stenosis by stenting (CAS) followed by coronary and noncoronary cardiac surgical intervention as proposed by our institution [2]. In our protocol, aspirin was started at least 2 days before CAS, and clopidogrel was added just 6 hours after the surgical procedure [2] in order to reduce the risk of early formation of platelet aggregates immediately after CAS, without increasing the risk of bleeding during the cardiac operation. Full-Text PDF