RAMB - Novembro 2017

eis

PFF

1014

ssoc

ras

2017; 63(11):1012-1016

perform endarterectomy synchronously to CABG without

extracorporeal circulation (ECC).

On the other hand, when evaluating data by Naylor and

Bown

regarding studies from1972 to 2002, results opposite

those of Fareed et al. are observed.

The worst outcomes,

including overall mortality, composite endpoint of death +

CVA and death + CVA + AMI were higher in patients sub-

mitted to synchronized surgery, respectively 4.6, 7.4, 8.7

and 11.5% compared with staged procedures. However,

the incidence of CVA alone, both ipsilateral in major ca-

rotid disease and CVA in any territory, was higher in CABG

prior to CAR; and the rate of AMI alone was higher in

patients submitted to CAR preceding CABG. It is impor-

tant to mention that the majority of patients were asymp-

tomatic from a neurological point of view, and there was

no standardized way to diagnose perioperative AMI, which

was therefore underdiagnosed.

Despite the divergence among studies, much can be

asked about the actual prevalence of CVA combined with

carotid disease. The fact is that most CVAs were diagnosed

after 24 hours of surgery, regardless of the territory of

carotid disease, and many of the patients did not have

significant carotid atherosclerosis.

According to recommendations byMasabni et al.,

when

choosing a carotid approach prior to CABG, both procedures

should be avoided at the same anesthetic time due to the

risk associated with hyperperfusion syndrome after carotid

revascularization, making it imperative to observe level of

consciousness and neurological parameters shortly after

the procedure. Another logical approach is that performed

by the teamof Seyed Ebrahim,

at the Tehran Heart Center,

which advocates prioritizing the treatment of the most

severe entity: in patients with symptoms of unstable angina

or asymptomatic carotid disease, only CABG is performed;

while in patients with stable coronary disease and symp-

tomatic carotid stenosis, the approach advocated is that of

carotid artery simultaneously with CABG. The common

sense is that the CAR option is based on patient comor-

bidities, CABG urgency, supra-aortic vessel anatomy and

medical center experience.

Such heterogeneity in the results of studies comparing

surgical techniques to approach these two entities reflects

the limited evidence in this scenario: the studies are most-

ly single-center studies composed of series of cases with

selection bias, so that the experience of the surgeon and

the service seems to have direct interference in the results.

ybrid

treatment

An alternative strategy for the management of patients

with CABG indication and those with significant carotid

stenosis is the hybrid procedure. It consists of PCI (angio-

plasty and stent placement) combined with CABG. It may

be synchronous (performed at the same surgical time) or

staged (performed at two different times), and associated

with CABG with or without ECC. It is another therapeutic

alternative based on the experience of certain services, in

series of cases, single-center studies and retrospective ana-

lyzes. Although there are no multicenter and prospective

studies that evaluate the superiority and safety of this

therapeutic approach to the detriment of others, it is an-

other alternative for the treatment of patients with coronary

artery disease and carotid stenosis in institutions with

structure and experience to carry out hybrid procedures.

The synchronic approach, using percutaneous treat-

ment with stent implantation in carotid lesions (≥ 60%

symptomatic or ≥ 70% asymptomatic) followed immedi-

ately by CABG, showed an incidence of 2.2% of CVA/death

after 30 days and absence of neurological complications

related to the percutaneous procedure and AMI. In this

single-center, prospective and nonrandomized study

(n=90), synchronic hybrid treatment was a reasonable

option for the selected group of patients.

The prospective/multicenter SHARP trial (n=101)

evaluated PCI associated with CABG at the same surgical

time in high-risk patients (EuroESCORE ≥ 5).

Simulta-

neous hybrid technique demonstrated 98% success in the

procedure and 2% cumulative incidence of AMI/CVA/

death within 30 days. It thus demonstrated a feasible and

promising approach for this group of patients.

Retrospective evaluation of the CARE

(Carotid Ar-

tery Revascularization) registry evaluated the clinical

characteristics of patients undergoing carotid endarter-

ectomy and percutaneous intervention of carotid lesions

immediately before CABG. Despite regional variations,

patients undergoing percutaneous intervention had more

advanced vascular disease, but less pre-surgical risk.

Patients with symptomatic carotid stenosis are four

times more likely to develop neurological complications

during CABG perioperative period. The hybrid treatment

was also evaluated in this group of patients (previous TIA/

CVA) in a prospective/single-center study (n=57). The

hybrid procedure was shown to be a viable alternative for

the treatment of this high-risk group, although the strat-

egy also lacks studies with a higher level of evidence for

recommendation to the detriment of other therapeutic

options in this context.

A prospective cohort compared the staged hybrid

treatment (prophylactic PCI followed by CABG) with

CABG (non-ECC) in 112 patients with significant ca-

rotid stenosis and CABG indication. Prophylactic percu-