The Safety And Efficacy Of Staged Carotid Artery Stenting And Coronary Artery Bypass Grafting In The Treatment Of Coronary Heart Disease Combined With Severe Carotid Artery Stenosis

Background:Coronary artery bypass grafting(CABG)is an effective treatment for patients with severe coronary heart disease,but patients who receive CABG are generally complicated with more underlying diseases and high surgical risk.How to prevent and treat postoperative complications of CABG has always been a research focus.Stroke is a serious complication after CABG,which can lead to permanent neurological damage,limb paralysis and even death.In the general population,stroke caused by carotid artery stenosis accounts for about 20% of all strokes,which is one of the main causes of stroke.Similarly,in the CABG population,a large number of studies have confirmed that severe carotid artery stenosis(carotid artery stenosis ≥ 70%)is one of the main risk factors for stroke after CABG,with or without neurological symptoms.Once stroke occurs after CABG,the mortality and disability rate is high,which greatly affects the prognosis and the quality of life of patients with CABG.It is urgent to develop safe and effective measures to reduce the incidence of stroke in patients after CABG.Carotid stent stenting(CAS)and carotid endarterectomy(CEA)are commonly used in the treatment of carotid stenosis.Simultaneous carotid revascularization in patients with severe carotid stenosis who are ready to receive CABG can theoretically reduce the incidence of stroke after CABG.The current management strategies mainly include: 1,staged CEA or CAS and CABG;2,CEA or CAS simultaneous CABG;3,CEA or CAS after CABG.Different treatment strategies have respective advantages and disadvantages.Domestic and international guidelines still have no consensus on the strategy of carotid revascularization and the timing of carotid artery intervention in patients with CABG.Staged CAS and CABG refers to the treatment of carotid artery stenosis with CAS,followed by CABG for coronary heart disease within the same hospital stay,which is relatively safe and easier to carry out and popularize,but there is still controversy about the safety and efficacy of this program.In recent years,a number of studies have shown that staged CAS and CABG strategy is safe and effective,but most of them are small-scale retrospective and single-arm studies,lack of control groups and randomized trials,and lack of convincing evidence.Need more research to confirm the efficacy and safety of the strategy.In this study,we compared the safety and efficacy of staged CAS and CABG strategy in the treatment of coronary heart disease with severe carotid artery stenosis by using isolated CABG patients with severe carotid artery stenosis as the control group.Objective:To analyze the safety and efficacy of staged carotid stent stenting and coronary artery bypass grafting in the treatment of coronary heart disease with severe carotid artery stenosis.Methods:According to the inclusion criteria and exclusion criteria,the clinical data of patients with severe carotid artery stenosis who underwent CABG in our hospital from March 2018 to March 2021 were analyzed retrospectively.There are 38 patients underwent CAS followed by CABG(staged CAS and CABG group),and 73 patients underwent CABG without intervention for carotid stenosis(isolated CABG group).The preoperative baseline data,intraoperative data,and the incidence of stroke,death,myocardial infarction and compound end point events(stroke,myocardial infarction,death caused by any reason)were compared and analyzed between the two groups,and the safety and efficacy of staged CAS and CABG in the treatment of coronary heart disease complicated with severe carotid artery stenosis were evaluated.Results:There was no significant difference in sex,age,history of hypertension,diabetes,hyperlipidemia,myocardial infarction,history of stroke or transient ischemic attack(TIA),smoking,preoperative cardiac EF,left main coronary artery disease,three-vessel coronary artery disease,other peripheral vascular diseases,incidence of bilateral carotid artery stenosis and degree of carotid artery stenosis between the two groups(P>0.05).There was no significant difference in the duration of CABG operation,the number of bypass branches,the duration of postoperative ventilator and the indwelling time of ICU between the two groups(P > 0.05).There was also no significant difference in intraoperative blood loss,postoperative erythrocyte transfusion,postoperative plasma transfusion,postoperative 24-hour drainage,total postoperative drainage and the incidence of postoperative renal insufficiency,postoperative arrhythmia and secondary thoracotomy between the two groups(P>0.05).A total of 40 carotid stents were implanted in 38 patients,with a technical success rate of 100%.After CAS,the degree of Carotid artery stenosis decreased from(86.32±8.60)% to(9.74±5.06)%.There are two patients had a decrease in blood pressure during the CAS operation,and one patient had a slow heart rate,all of which improved after symptomatic treatment.The interval between CAS and CABG was(13.32±3.86)days.During the interval,one patient had angina pectoris and improved after symptomatic treatment.There was no secondary thoracotomy and death in staged CAS and CABG group.In the isolated CABG group,one patient died of severe respiratory failure,5 patients had stroke in different degrees within thirty days after CABG,and there was no postoperative myocardial infarction and secondary thoracotomy.The incidence of stroke within thirty days after CABG in the staged CAS and CABG group was lower than that in the isolated CABG group,but the difference was not statistically significant(0.00% vs 6.85%,P=0.243).There was no significant difference in the incidence of myocardial infarction,mortality and the incidence of compound end point events within thirty days after CABG between the two groups(P >0.05).The incidence of stroke in the staged CAS and CABG group was significantly lower than that in the isolated CABG group within one year after CABG,and the difference was statistically significant(2.63%vs 17.81%,P=0.047).There was no significant difference in the incidence of myocardial infarction and mortality between the two groups within one year after CABG.The incidence of compound events in the CAS staging CABG group was lower than that in the isolated CABG group wthin one year after CABG,and the difference was statistically significant(2.63% vs 19.18%,P=0.016).Conclusion:Staged CAS and CABG can significantly reduce the incidence of stroke and compound end point events within one year after CABG.It is a safe and effective strategy for the treatment of patients with coronary heart disease combined with severe carotid artery stenosis.