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Safety And Feasibility Of Same-admission Tcar Prior To Heart Surgery For Patients Presenting With Concurrent, Severe Carotid Artery Stenosis And Surgical Cardiac Disease
Brittany Landavazo1, Matthew Kenny
1, Chandler Vernon
2, Shir Yelovitch, PhD
3, Nicolas Zea, MD
3, Jeffrey Apple, MD
3, David Nation, MD
3, Kofi Quaye, MD
3, Ryan Turley, MD
3.
1Texas A&M College of Medicine, Round Rock, TX, USA,
2Texas A&M University, College Station, TX, USA,
3Cardiothoracic & Vascular Surgeons, Austin, TX, USA.
Objective: Up to 70% of patients with critical coronary artery disease (CAD) also present with significant carotid artery stenosis. The optimal treatment for these patients has long been debated, with open carotid revascularization generally reserved for those with severe symptomatic carotid disease that precludes cardiac surgery. In this scenario, the role of less-invasive carotid artery stenting, particularly transcarotid arterial revascularization (TCAR), remains controversial and is not yet well studied. This study aims to present our outcomes and methodology for treating severe carotid stenosis with TCAR prior to cardiac surgery.
Methods: A retrospective chart review of the previous 656 TCAR procedures performed from 2013 to 2024 identified 16 TCARs conducted during the same hospital admission before cardiac surgery. The primary endpoint was 30-day stroke and myocardial infarction (MI). Secondary endpoints included operative time, cranial nerve injury, neck hematoma, length of stay, arterial dissection, and death.
Results: Sixteen patients underwent TCAR before cardiac surgery. Of these, 75.0% were male, with a median (IQR) age of 65.1(59.6-72.4) years.
Table 1 lists the preoperative comorbidities, percent carotid stenosis, TCAR operative details, discharge medical therapies, and indication for cardiac surgery. Bridging anticoagulation treatment included aspirin and either heparin infusion (56.3%,N=9), IV antiplatelet therapy (cangrelor or eptifibatide) (31.3%,N=5), or subcutaneous enoxaparin (12.5%,N=2). No patients experienced MI, stroke, CN injury, neck hematoma, or arterial dissection within 30 days. One (6.3%) patient required exploratory surgery within 30 days for mediastinal bleeding. One (6.3%) death occurred 30 days postoperatively due to infective mitral valve complications.
Conclusions: Our initial experience with TCAR prior to cardiac surgery suggests that it is reasonably safe and does not increase the risk of bleeding or cerebrovascular complications. Moreover, severe cardiac disease should not be considered a contraindication for TCAR with general anesthesia. In our experience, aspirin combined with either heparin infusion, IV antiplatelet therapy, or low molecular weight heparin has been effective until the cardiac surgeon deems it safe to initiate oral dual antiplatelet therapy (DAPT). Further studies with larger datasets are required to support the broader adoption of TCAR prior to heart surgery in patients with concurrent, severe cardiac and carotid disease.
| |
| Preoperative Comorbidities | n (%) |
| Asymptomatic | 13 (81.25%) |
| Congestive Heart Failure | 5 (31.25%) |
| End Stage Renal Disease on Dialysis | 2 (12.50%) |
| Prior Neck Surgery | 3 (18.75%) |
| Previous Carotid endarterectomy | 1 (6.25%) |
| Percentage of Carotid Stenosis | n (%) |
| 70%-79% | 4 (25.00%) |
| 80%-89% | 9 (56.25%) |
| 90% | 3 (18.75%) |
| TCAR Stent Details | n (%) |
| Number of stents | |
| 1 | 16 (100%) |
| Predilation (mm) | |
| None | 8 (50.0%) |
| 4 | 3 (18.75%) |
| 5 | 4 (25.0%) |
| 6 | 1 (6.25%) |
| Postdilation (mm) | |
| None | 2 (12.50%) |
| 5 | 6 (37.50%) |
| 5.5 | 4 (25.0%) |
| 6 | 4 (25.0%) |
| Stent sizes (mm) | |
| 7 x 30 | 1 (6.25%) |
| 8 x 30 | 5 (31.25%) |
| 8 x 40 | 7 (43.75%) |
| 9 x 40 | 3 (18.75%) |
| TCAR Operative Details | |
| Median Contrast Volume (cc/mL) | 20.0 (15.0-27.5) |
| Type of Anesthesia | |
| General | 13 (81.25%) |
| Local + Sedation | 3 (18.75%) |
| Median Operative Time (minutes) | |
| Skin to Skin | 50.0 (41.75-60.0) |
| Flow Reversal | 9.0 (6.0-13.0) |
| Median time from TCAR to Cardiac Surgery (days) | 2.0 (1.0-2.0) |
| Median Length of Stay (days) | 9.0 (6.25-15.50) |
| Indication for Cardiac Surgery | n (%) |
| Multivessel CAD | 9 (56.25%) |
| CAD with Left Ventricle Dysfunction | 3 (18.75%) |
| CAD of the Left Main | 3 (18.75%) |
| CAD with Mitral Valve Endocarditis | 1 (6.25%) |
| Discharge Medical Therapy | n (%) |
| Aspirin | 15 (93.75%) |
| Statin | 14 (87.50%) |
| Non-Aspirin Antiplatelet(Clopidogrel, Prasugrel, Ticagrelor) | 14 (87.50%) |
| Direct Oral Anticoagulants(Apixaban, Rivaroxaban, Enoxaparin) | 3 (18.75%) |
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