Concomitant Carotid Artery Disease Research Articles

Prognosis and factors related to anti-VEGF therapy in patients with retinal vein occlusion and concomitant carotid artery disease

To evaluate the prognosis and influencing factors of retinal vein occlusion (RVO) in patients with concomitant carotid artery disease receiving anti-vascular endothelial growth factor (VEGF) treatment. Patients diagnosed with RVO and receiving anti-VEGF treatment were included. Eye and clinical data were collected. The patients were divided into a group with concomitant carotid artery disease (Group A) and a group without concomitant carotid artery disease (Group B). The risk factors affecting the visual prognosis of RVO patients with concomitant carotid artery disease were analyzed. Among 177 eligible patients with RVO, 101 had concomitant carotid artery disease (Group A), while 76 did not (Group B). Group A had a significantly lower treatment effectiveness rate than Group B (P < 0.001). The age and platelet distribution width of Group A were significantly higher than Group B (P < 0.001). Multivariate logistic regression analysis showed that baseline best-corrected visual acuity (BCVA), disorganization of retinal inner layers (DRIL), external limiting membrane (ELM) disruption, and red blood cell distribution width (RDW) were significantly associated with the posttreatment visual prognosis of RVO patients with concomitant carotid artery disease(P < 0.05). RVO patients with concomitant carotid artery disease had a significantly lower treatment effectiveness rate than RVO patients without carotid artery disease. The poor baseline BCVA, DRIL, ELM disruption, and a greater RDW are risk factors for low anti-VEGF treatment efficacy among RVO patients with concomitant carotid artery disease.

Epidemiological Aspects of the Carotid Artery Disease in Patients Undergoing Coronary Artery Bypass Grafting: A Cross-sectional Study

Background and aims: Concomitant carotid artery disease (CaAD) in patients referred to coronary surgical revascularization is a strong hazard to perioperative stroke. The current study addressed the epidemiology features of concomitant CaAD in patients referred to a coronary surgical revascularization center. Methods: This descriptive-analytical cross-sectional study was conducted on all incoming patients to coronary surgical revascularization for two years at a single center who underwent a color duplex-sonography (CDS) interrogation. The demographic, clinical, echocardiographic, coronary angiographic, and color duplex-sonographic data were collected from patients’ medical records. Quantitative and qualitative data were expressed as means and standard deviations, as well as numbers and percentages, respectively. The relationships between quantitative and qualitative variables were investigated using Pearson’s correlation and chi-square test, respectively. Results: In total, 430 patients with a mean age of 66.3±9.9 years were included (35% females) in the study. Preoperative CDS was performed on 82% of patients; in addition, 29% of them presented with an increased intima-media ratio, and CtAD was observed in 51%. Based on the results, 77 and 143 patients were detected with unilateral and bilateral involvement, respectively. Severe carotid stenosis accounted for 4% of patients. Age older than 65 years (P=0.02), unstable angina (P=0.045), and the presence of an occluded coronary artery (P=0.002) were associated with the presence of CtAD. Finally, the severity of the left and right carotid stenosis was associated with diabetes mellitus (P&lt;0.05). Conclusion: The prevalence of concomitant CtAD in patients referred to coronary surgical revascularization remains high. The current data warn of the necessity of performing preoperative CDS routinely.

ABCA1 and ABCG1 DNA methylation in epicardial adipose tissue of patients with coronary artery disease

BackgroundRecent studies have focused on the potential role of epicardial adipose tissue (EAT) in the development of coronary artery disease (CAD). ABCA1 and ABCG1 transporters regulate cell cholesterol content and reverse cholesterol transport. We aimed to determine whether DNA methylation and mRNA levels of the ABCA1 and ABCG1 genes in EAT and subcutaneous adipose tissue (SAT) were associated with CAD.MethodsPaired EAT and SAT samples were collected from 82 patients undergoing elective cardiac surgery either for coronary artery bypass grafting (CAD group, N = 66) or valve surgery (NCAD group, N = 16). ABCA1 and ABCG1 mRNA levels in EAT and SAT samples were analyzed using real time polymerase chain reaction, ABCA1 protein levels in EAT samples were assessed by western blotting. ABCA1 and ABCG1 DNA methylation analysis was performed in 24 samples from the CAD group and 9 samples from the NCAD group via pyrosequencing.ResultsDNA methylation levels in the ABCA1 promoter and ABCG1 cg27243685 and cg06500161 CpG sites were higher in EAT samples from patients with CAD compared with NCAD (21.92% vs 10.81%, p = 0.003; 71.51% vs 68.42%, p = 0.024; 46.11% vs 37.79%, p = 0.016, respectively). In patients with CAD, ABCA1 and ABCG1 DNA methylation levels were higher in EAT than in SAT samples (p < 0.05). ABCA1 mRNA levels in EAT samples were reduced in the subgroup of patients with CAD and concomitant carotid artery disease or peripheral artery disease compared with the NCAD group (p = 0.024). ABCA1 protein levels in EAT samples tended to be lower in CAD patients than in the NCAD group (p = 0.053). DNA methylation levels at the ABCG1 cg27243685 site positively correlated with plasma triglyceride concentration (r = 0.510, p = 0.008), body mass index (r = 0.556, p = 0.013) and waist-to-hip ratio (r = 0.504, p = 0.012) in SAT samples.ConclusionCAD is associated with ABCA1 and ABCG1 DNA hypermethylation in EAT. CAD with concomitant carotid artery disease or peripheral artery disease is accompanied by decreased ABCA1 gene expression in EAT. DNA methylation levels at the ABCG1 cg27243685 locus in SAT are associated with hypertriglyceridemia and obesity.

Invited Commentary

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

Simultaneous Carotid Artery Stenting and Heart Surgery: Expanded Experience of Hybrid Surgical Procedures

The 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. One hundred thirty-two consecutive patients (70 ± 8 years, 102 men) underwent same-day CAS and CABG (group 1, n= 97) or other cardiac surgical procedures (aortic ± mitral valve surgery ± ascending aorta replacement ± CABG; group 2, n= 35). In both groups aspirin (100 mg daily) was started 2 days before CAS and permanently continued; clopidogrel, 300 mg initially followed by 75 mg daily, was started 6 hours after surgery and discontinued 1 month later. In group 2, when required, warfarin was started and aspirin discontinued on the second postoperative day. Mean follow-up was 53 ± 24 months. Overall in-hospital mortality was 3.8% (2.1% in group 1 versus 8.6% in group 2; p= 0.02; 0% for noncoronary isolated procedures, 20% for complex cases), perioperative myocardial infarction was 0%, and stroke was 0.75% (0% in group 1 versus 2.86% in group 2; p= 0.26). Late survival was 81% ± 10% (92% ± 3.2% in group 1 versus 80% ± 11% in group 2; p= 0.45), and overall freedom from neurologic events was 84% ± 6%. Same-day hybrid approach appeared safe in terms of early and long-term results not only for CAS and isolated CABG but also for CAS and noncoronary isolated procedures. In complex cases, the rate of stroke and myocardial infarction seemed low; in-hospital mortality, as expected, was higher. Long-term survival appeared similarly satisfactory, thus confirming the hybrid approach as a valid therapeutic option for all patients with significant internal carotid artery stenosis associated with coronary and other cardiac lesions, at least for noncomplex cases.

Left Main Coronary Artery Disease as a Predictor of Concomitant Carotid Artery Disease

Left Main Coronary Artery Disease as a Predictor of Concomitant Carotid Artery Disease

Early outcome and recurrences after cardiogenic brain embolism.

Functional outcome and recurrence rate were evaluated retrospectively in a series of 566 consecutive patients with a cardioembolic TIA or stroke. Seventy-five patients had a TIA/RIND, 163 a minor stroke, 238 a major deficit, and 90 a fatal event. In a logistic regression analysis the probability of a disabling or fatal outcome was significantly influenced by age (p = 0.0023), a previous stroke (p = 0.0262), concomitant carotid artery disease in Doppler sonography (p = 0.0210), and the underlying heart disease (p = 0.0001). Fatal or major strokes predominated among patients with nonvalvular atrial fibrillation, prosthetic heart valves, acute or chronic myocardial infarction. Kaplan-Meier estimates revealed a cumulative risk of recurrent cerebral embolism of 2.9% within three weeks. In a proportional hazards model only the underlying heart disease was significantly linked with the risk of recurrent embolism (p = 0.021).

Invited commentary

Perioperative stroke arguably remains the worst complication of surgical myocardial revascularization, being devastating for the patient and family, contributing to significantly elevated early and late mortality rates, and markedly increasing the costs of subsequent care. Unfortunately the overall incidence of perioperative stroke has not diminished significantly because of the aging and worsening risk profile of current patient populations. However, increasing appreciation of the contribution of significant concomitant carotid artery disease to the stroke risk of patients with important coronary artery disease has led many cardiac surgeons to more aggressive surgical approaches directed at treating both disease processes. This report by Zacharias and colleagues of a large contemporaneous experience with the simultaneous management of the two diseases during one anesthetic demonstrates that well-performed concomitant carotid endarterectomy and coronary artery bypass grafting can effectively neutralize unilateral significant carotid artery stenosis as a risk factor for perioperative stroke.The authors have not only achieved excellent operative mortality and morbidity rates, but they have demonstrated by comparison to the rest of their coronary bypass patients that the concomitant approach has not increased the risk of death or complications. In fact they have reported observed results that are better than would have been predicted if they had ignored the associated carotid artery disease and performed only myocardial revascularization.Whether similar excellent results could have been achieved with staged carotid endarterectomy and coronary artery bypass grafting may be open to debate. What is not debatable is that the simultaneous operative approach is less costly. Previous attempts to organize large, multiinstitutional, randomized trials of concomitant versus staged operative procedures have met with little success. Given the economic advantage associated with and proved for simultaneous procedures, any future randomized trial would have to demonstrate not only that the early and late outcomes of the two approaches were comparable, but also that they were equally cost-effective.Until such trials are performed, cardiac surgeons should at least recognize the importance of dealing with the two disease processes in a timely fashion, whether it be simultaneous or staged. To ignore significant carotid disease when performing surgical myocardial revascularization is to potentially commit the patient to a less than optimal result. Perioperative stroke arguably remains the worst complication of surgical myocardial revascularization, being devastating for the patient and family, contributing to significantly elevated early and late mortality rates, and markedly increasing the costs of subsequent care. Unfortunately the overall incidence of perioperative stroke has not diminished significantly because of the aging and worsening risk profile of current patient populations. However, increasing appreciation of the contribution of significant concomitant carotid artery disease to the stroke risk of patients with important coronary artery disease has led many cardiac surgeons to more aggressive surgical approaches directed at treating both disease processes. This report by Zacharias and colleagues of a large contemporaneous experience with the simultaneous management of the two diseases during one anesthetic demonstrates that well-performed concomitant carotid endarterectomy and coronary artery bypass grafting can effectively neutralize unilateral significant carotid artery stenosis as a risk factor for perioperative stroke. The authors have not only achieved excellent operative mortality and morbidity rates, but they have demonstrated by comparison to the rest of their coronary bypass patients that the concomitant approach has not increased the risk of death or complications. In fact they have reported observed results that are better than would have been predicted if they had ignored the associated carotid artery disease and performed only myocardial revascularization. Whether similar excellent results could have been achieved with staged carotid endarterectomy and coronary artery bypass grafting may be open to debate. What is not debatable is that the simultaneous operative approach is less costly. Previous attempts to organize large, multiinstitutional, randomized trials of concomitant versus staged operative procedures have met with little success. Given the economic advantage associated with and proved for simultaneous procedures, any future randomized trial would have to demonstrate not only that the early and late outcomes of the two approaches were comparable, but also that they were equally cost-effective. Until such trials are performed, cardiac surgeons should at least recognize the importance of dealing with the two disease processes in a timely fashion, whether it be simultaneous or staged. To ignore significant carotid disease when performing surgical myocardial revascularization is to potentially commit the patient to a less than optimal result.

Long-term results and outcomes of crossover axilloaxillary bypass grafting: A 24-year experience

Objective: The outcome of crossover axilloaxillary bypass grafting in patients with stenosis or occlusion of the innominate or subclavian arteries was investigated. Methods: The study was designed as a retrospective clinical study in a university hospital setting with 61 patients as the basis of the study. Fifty-eight patients (95.1%) had at least two risk factors or associated medical illnesses for atherosclerosis, and 35 patients (57.4%) had concomitant carotid artery stenosis that necessitated a staged procedure in 12 patients (19.7%). The patients underwent a total of 63 crossover axilloaxillary bypass grafting procedures. Demographics, risk factors and associated medical illnesses, preoperative symptoms and angiographic data, blood flow inversion in the vertebral artery, concomitant carotid artery disease, graft shape, caliber and material, and intraoperative and postoperative complications were studied to assess the specific influence in determining the outcome. Results: One postoperative death (1.6%), four early graft thromboses (6.2%), and six minor complications (9.8%) occurred. The overall mortality and morbidity rates were 1.6% and 16.1%, respectively. During the follow-up period (mean, 97.3 ± 7.9 months), we observed five graft thromboses (8.3%). Primary and secondary patency rates at 5 and 10 years were 86.5% and 82.8% and 88.1% and 84.3%, respectively. Overall, two patients (3.3%) had recurrence of upper limb symptoms and none had recurrence of symptoms in the carotid or vertebrobasilar territory. The 5-year and 10-year symptom-free interval rates were 97.7% and 93.5%, respectively. Nine patients (15%) died of unrelated causes. The 5-year and 10-year survival rates were 93.2% and 67.3%, respectively. Multivariate analysis showed that no specific variables exerted an influence in the short-term and long-term results and the outcome. Conclusion: The optimal outcome of axilloaxillary bypass grafting supports its use as the most valuable surgical alternative to transthoracic anatomic reconstructions for innominate lesion, long stenosis of the subclavian artery, and short subclavian artery stenosis associated with ispilateral carotid artery lesions. (J Vasc Surg 1999;29:894-901.)

Coronary-Subclavian Steal with Concomitant Carotid Disease: Indication for Axilloaxillary Bypass

Coronary-subclavian steal syndrome is a potential complication of coronary artery bypass grafting when the internal mammary artery is used as a conduit. Concomitant carotid artery disease complicates the syndrome by introducing a possible simultaneous cerebral steal phenomenon. The authors present the first reported case of a patient who had symptomatic coronary-subclavian steal with significant carotid occlusive disease. An axilloaxillary bypass was performed instead of the standard carotid-subclavian bypass. Recommendations concerning the diagnosis and management of this syndrome are presented and the indication for axilloaxillary bypass is outlined.

Long-term prognosis of infratentorial transient ischemic attacks and minor strokes.

This study was performed to gather information about long-term prognosis after infratentorial transient ischemic attacks and minor strokes and about the factors influencing it. We included 226 patients with transient ischemia and 169 patients with a minor stroke of the brain stem/cerebellum consecutively admitted to a neurological department. Medical records and the findings of computed tomography, Doppler ultrasonography, and angiography were evaluated retrospectively. Follow-up information was gathered from the patients and their physicians by questionnaires. Complete follow-up information was available for 381 patients. During a mean follow-up of 3.9 years, 15.7% of the 381 patients suffered a stroke and 6.8% a myocardial infarction; 15% died. Kaplan-Meier estimates revealed a cumulative stroke rate of 5.1% within the first year and a risk of stroke, myocardial infarction, or death of any cause of 9.8%. In a proportional hazards model, the time-dependent risk of stroke was significantly increased by increasing age (p = 0.018), minor stroke (p = 0.0005), hypertension (p = 0.022), previous stroke (p = 0.0006), and carotid artery occlusive disease (p = 0.0065). The probability of stroke, myocardial infarction, or death was influenced by age (p = 0.0001), minor stroke (p = 0.006), diabetes (p = 0.015), previous stroke (p = 0.002), infarct on a computed tomogram (p = 0.041), and carotid artery disease (p = 0.032). Long-term prognosis after brain stem/cerebellar transient ischemic attacks and minor strokes is significantly influenced by age, diabetes, hypertension, previous stroke, and concomitant carotid artery disease. Patients with transient ischemic attacks have a better prognosis than those with minor stroke.