Department of Cardiac and Vascular Diseases, Jagiellonian University, Cracow, Poland.
Med Sci Monit. 2011 Aug;17(8):RA191-197. doi: 10.12659/msm.881896.
Coexistent carotid artery stenosis (CS) and multivessel coronary artery disease (CAD) is not infrequent. One in 5 patients with multivessel CAD has a severe CS, and CAD incidence reaches 80% in those referred for carotid revascularization. We reviewed treatment strategies for concomitant severe CS and CAD. We performed a literature search (MEDLINE) with terms including carotid artery stenting (CAS), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), stroke, and myocardial infarction (MI). The main therapeutic option for CS-CAD has been (simultaneous or staged) CEA-CABG. This, however, is associated with a high risk of MI (in those with CEA prior to CABG) or stroke (CABG prior to CEA), and the cumulative major adverse event rate (MAE - death, stroke or MI) reaches 10-12%. With increasing adoption of CAS, a sequential strategy of CAS followed by CABG has emerged. Registries (usually single-centre) indicate an MAE rate of ≈7% for CAS followed by CABG (frequently after >30 days, due to double antiplatelet therapy). Recently, 1-stage CAS-CABG has been introduced. This involves different antiplatelet regimens and, in some centers, preferred off-pump CABG, with a cumulative MAE of 1.4-4.5%. No randomized trial comparing different treatment strategies in CS-CAD has been conducted, and thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-centre, studies are required before this can become widely applied.
同时存在颈动脉狭窄（CS）和多支冠状动脉疾病（CAD）并不罕见。5 分之一的多支 CAD 患者存在严重的 CS，而在那些需要进行颈动脉血运重建的患者中，CAD 的发生率达到 80%。我们回顾了同时存在严重 CS 和 CAD 的治疗策略。我们使用颈动脉支架置入术（CAS）、冠状动脉旁路移植术（CABG）、颈动脉内膜切除术（CEA）、中风和心肌梗死（MI）等术语进行了文献检索（MEDLINE）。CS-CAD 的主要治疗选择一直是（同期或分期）CEA-CABG。然而，这与 MI（在 CEA 之前进行 CABG 的患者中）或中风（在 CABG 之前进行 CEA 的患者中）的高风险相关，累积主要不良事件率（MAE-死亡、中风或 MI）达到 10-12%。随着 CAS 的广泛应用，出现了 CAS 后序贯 CABG 的策略。登记处（通常为单中心）表明，CAS 后序贯 CABG 的 MAE 率约为 7%（由于双联抗血小板治疗，通常在 30 天后进行）。最近，引入了 1 期 CAS-CABG。这涉及不同的抗血小板治疗方案，在一些中心，更倾向于非体外循环 CABG，累积 MAE 为 1.4-4.5%。目前尚未进行比较 CS-CAD 不同治疗策略的随机试验，到目前为止，报告的系列研究容易受到选择/报告偏倚的影响。除了既定的手术治疗（CEA-CABG、同期/序贯）之外，杂交血运重建（CAS-CABG）正在成为一种可行的治疗选择。在广泛应用之前，需要进行更大的、最好是多中心的研究。
