Success with Stents to Bring Back Blood Flow

Coronary heart disease patients with blocked carotid artery improve outcomes with stents and surgery

(RxWiki News) When a critical blood vessel in the neck becomes severely narrowed, a surgical procedure is often used to remove the blockage. A less-common method, however, may have better results.

The two carotid arteries feed vital blood to the brain. If one of these blood vessels becomes blocked by plaque buildup, a healthcare professional may remove the plaque with a surgical procedure called a carotid endarterectomy. The National Stroke Association says that this is the most common surgery for removing fatty deposits in these arteries.

A new study found that a procedure using stents (mesh tubes that prop open blood vessels) in these arteries, followed by open heart surgery a few weeks later, may lead to better outcomes for patients who have severe carotid and coronary artery disease.

"Consider surgery options to treat severely blocked arteries."

For this study, Mehdi Shishehbor, DO, PhD, director of endovascular services in the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic, and his colleagues examined results of 350 patients who had a procedure to restore blood flow (revascularization) to a carotid artery before having open heart surgery.

About 80 percent of the patients were asymptomatic — they had not had a stroke or heart attack within the previous six months.

Patients received one of three revascularization procedures within 90 days of a planned open heart surgery at Cleveland Clinic between January 1997 and August 2009.

One treatment group of 195 patients had endarterectomy and bypass surgery at the same time. Another 45 patients underwent endarterectomy followed by bypass surgery a couple weeks later. A third group of 110 had stents put in to open their blockage and then had surgery a few weeks later.

In an endarterectomy, a surgeon cuts open the neck to expose the artery. After clamping it, the surgeon then cuts lengthwise in the area where the blockage has been detected. The doctor then scrapes the fatty plaque from the area, inserts a diamond-shaped patch that enlarges the artery and stitches the artery back up.

With a stenting procedure, a doctor typically feeds a thin tube called a catheter through a major artery in the groin. The tube is maneuvered to the blocked area in the carotid artery. A balloon on the catheter is inflated flattening the plaque into the artery wall. When it’s deflated, a stent is left behind to keep the artery opened.

The researchers observed that, during the first year after the procedures, the stent group and the group that had the carotid arteries scraped with simultaneous heart surgery were less likely to die or have a heart attack or stroke than the remaining group.

After the first year and for years thereafter, however, scientists noted a significantly lower risk of serious events in the stent group compared with both endarterectomy groups.

Dr. Shishehbor told dailyRx News that the patients who received stents followed by surgery were 65 percent less likely to have a heart attack, suffer a stroke or die compared with the other two groups.

"Our study shows that carotid stenting followed by open heart surgery should be the first line strategy for treating patients with severe carotid and coronary disease, if the three- to four-week wait between procedures is clinically acceptable," said Dr. Shishehbor in a press release.

According to information from the Cleveland Clinic, currently only 3 percent of patients with both severe carotid and coronary artery disease receive carotid stenting followed by open heart surgery.

When asked why this procedure was not used more often, Dr. Shishehbor told dailyRx News that Medicare and Medicaid policies are part of the reason. They reimburse for endarterectomy procedures to treat asymptomatic patients but do not reimburse for carotid stent procedures in patients with coronary heart disease.

Dr. Shishehbor also pointed out that the stenting procedure in the neck is not allowed to be performed at the same time as bypass surgery in asymptomatic patients. Although Europe allows the two procedures to be performed at the same time, US protocol requires that asymptomatic patients receive three to four weeks of antiplatelet treatment with aspirin and clopidogrel (brand name Plavix) before undergoing open heart surgery.

The results were published July 31 in the Journal of the American College of Cardiology. Dr. Shishehbor is speaker and consultant for Abbott Vascular, Medtronic and GORE but has waived all compensations for this work.

Review Date: 
August 2, 2013