Carotid Stenting Prior to Coronary Bypass Surgery: An Updated Systematic Review and Meta-Analysis

OBJECTIVES: The aim was to determine 30-day outcomes in patients with concurrent carotid and cardiac disease who underwent carotid artery stenting (CAS) followed by coronary artery bypass grafting (CABG). METHODS: This was a systematic review with searches of PubMed/Medline, Embase, and Cochrane databases. "Same-day" procedures involved CAS + CABG being performed on the same day, and "staged" interventions involved at least 1 day's delay between undergoing CAS and then CABG. RESULTS: There were 31 eligible studies (2727 patients), with 80% being neurologically asymptomatic with unilateral stenoses. Overall, the 30-day death/stroke rate was 7.9% (95% confidence interval [CI] 6.9-9.2), while death/stroke/MI was 8.8% (95% CI 7.3-10.5). Staged CAS + CABG was associated with 30-day death/stroke rate of 8.5% (95% CI 7.3-9.7) compared with 5.9% (95% CI 4.0-8.5) after "same-day" procedures. Outcomes following CAS + CABG in neurologically symptomatic patients were poorer, with procedural stroke rates of 15%. There were five antiplatelet (APRx) strategies: (a) no APRx (death/stroke/MI, 4.2%; no data on bleeding complications); (b) single APRx before CAS and CABG, then dual APRx after CABG (death/stroke/MI, 6.7%; 7.3% bleeding complications); (c) dual APRx pre-CAS down to one APRx pre-CABG (death/stroke/MI, 10.1%; 2.8% bleeding complications); (d) dual APRx pre-CAS, both stopped pre-CABG (death/stroke/MI, 14.4%); (e) dual APRx pre-CAS and continued through CABG (death/stroke/MI, 16%). There were insufficient data on bleeding complication in the last two strategies. CONCLUSIONS: In a cohort of predominantly asymptomatic patients with unilateral carotid stenoses, the 30-day rate of death/stroke was about 8%. Notwithstanding the effect of potential biases, this meta-analysis did not find evidence that outcomes after same-day CAS + CABG were higher than after staged interventions. However, outcomes were poorer in neurologically symptomatic patients. More data are required to establish the optimal antiplatelet strategy in patients undergoing same-day or staged CAS + CABG.