Department of Surgery, University of Texas Medical Branch, Galveston, TX.
Department of Surgery, St. Luke's University Health Network, Bethlehem, PA.
J Vasc Surg. 2023 Oct;78(4):1083-1094.e8. doi: 10.1016/j.jvs.2023.04.043. Epub 2023 May 29.
Stroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate.
We aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS).
Two randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively).
CEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.
中风是冠状动脉旁路移植术（CABG）后的一种严重并发症。据报道，颈动脉粥样硬化疾病是独立的危险因素。这些患者的最佳治疗策略仍存在争议。
我们旨在通过比较围手术期不良事件发生率，进行网络荟萃分析评估同时患有颈动脉粥样硬化疾病且需要 CABG 的患者进行额外颈动脉介入治疗的安全性和疗效。通过 MEDLINE 和 EMBASE 检索截至 2022 年 2 月的所有文章，以确定仅调查 CABG 结果的研究以及通过颈动脉内膜切除术（CEA）和颈动脉支架置入术（CAS）进行分期与联合颈动脉介入治疗的研究。
纳入了 2 项随机对照试验和 23 项观察性研究，共纳入 32473 例同时接受联合 CEA 和 CABG（n=20204）、CEA 和分期 CABG（n=6882）、CABG 和分期 CEA（n=340）、无论时机和顺序均接受 CAS 和 CABG（n=1224）以及仅接受 CABG（n=3823）治疗的患者。在所有围手术期结局中，没有任何策略明显优于仅接受 CABG。CEA 和分期 CABG 的围手术期卒中/短暂性脑缺血发作（TIA）发生率最低，与 CAS 和 CABG（比值比[OR]，0.52；95%置信区间[CI]，0.36-0.76）以及 CABG 和分期 CEA（OR，0.41；95%CI，0.23-0.74）相比，显著降低，但也与围手术期死亡率（OR，2.50；95%CI，1.67-3.85，与 CAS 和 CABG 相比）和心肌梗死发生率（OR，3.70 [95%CI，1.16-12.5]和 OR，2.50 [95%CI，1.35-4.55]与 CAS 和 CABG 相比）最高相关。
CEA 和分期 CABG 与较低的围手术期卒中/TIA 发生率相关，但死亡率和心肌梗死发生率较高。在所有围手术期结局中，没有任何策略明显优于仅接受 CABG 的策略，这突出了制定个体化方法和确定这些患者颈动脉介入治疗适应证的重要性。
