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Staged Carotid Stenting

Heart & Vascular Institute Physician eNewsletter - Fall 2013

When it comes to carotid revascularization in the open heart surgery (OHS) population, the newest and least used alternative — staged carotid artery stenting (CAS) followed by OHS — edged out more widely used approaches beyond the short term.

A recent retrospective study conducted at Cleveland Clinic found that patients with severe carotid and coronary artery disease (CAD) whose physicians opted for CAS followed 3 to 4 weeks later by OHS fared better after 1 year than patients who underwent either of two more common surgical scenarios — staged carotid endarterectomy (CEA) followed by OHS, or combined CEA and OHS.

The study, which was published recently in the Journal of the American College of Cardiology, analyzed short-term and 1-year outcomes in 350 patients who underwent carotid revascularization within 90 days prior to OHS. The analysis included 45 staged CEA-OHS, 195 combined CEA-OHS, and 110 staged CAS-OHS.

In the short term, staged CAS-OHS and combined CEA-OHS were associated with similar risk of the composite primary endpoint of all-cause mortality, stroke or myocardial infarction (MI). Staged CEA-OHS patients had the highest short-term risk, driven by inter-stage MI. The study was one of the first that has specifically looked at the MI rate between CAS or CEA and OHS.

After 1 year: staged CAS-OHS fares best

After the first year, outcomes significantly favored staged CAS-OHS over both staged and combined CEA.

“The relative reduced risk over a period longer than 1 year was 67 percent for staged stenting vs. staged endarterectomy, and 65 percent for staged stenting vs. the combined procedure,” says Mehdi H. Shishehbor, DO, MPH, PhD, lead author of the study and director of endovascular services in Cleveland Clinic’s Department of Cardiovascular Medicine. The difference after the first year was due primarily to a higher all-cause mortality rate in the staged and combined CEA groups, he says.

“Of note, the patients who underwent staged stenting included patients who had a higher number of prior procedures and more complex bypass surgery, yet they had better longer-term outcomes,” Dr. Shishehbor says.

Clinical implications

Although no randomized clinical trials have yet been performed, Dr. Shishehbor says that the recent findings may be enough to support staged CAS-OHS as a first-line treatment in this patient population, in cases in which the waiting period prior to OHS is clinically acceptable.

“As a result of this work, we’re making changes to the way we approach patients with severe carotid and coronary artery disease,” Dr. Shishehbor says. “We are collaborating across disciplines to identify the lowest risk treatment option for each patient.”

Possible hurdles

Currently, only about 3 percent of patients in the United States with severe carotid and CAD undergo CAS-OHS, primarily because of Medicare-mandated registries that require waiting period between procedures. “More than 95 percent of patients will choose to undergo procedures that might not deliver the best results because of issues related to waiting for 3 to 4 weeks,” Dr. Shishehbor explains.

In addition, Medicare reimbursement requires that centers be certified by the Centers for Medicare and Medicaid Services (CMS) to perform CAS, and stringent clinical and treatment criteria also must be met. Dr. Shishehbor proposes that once additional studies confirm specific groups of patients that can benefit most from staged CAS-OHS, perhaps Medicare coverage will be expanded so that the required 3- to 4-week waiting period could be bypassed.

Reviewed: 09/13

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