Safety and Feasibility of Same-Admission Transcarotid Arterial Revascularization Prior to Heart Surgery for Patients Presenting With Concurrent, Severe Carotid Artery Stenosis, and Surgical Cardiac Disease.

Abstract

Introduction: Carotid artery stenosis and coronary artery disease are often co-morbid, with a prevalence of concurrent carotid and coronary artery stenosis approaching 50%. 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 15 TCAR procedures 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 (CN) injury, neck hematoma, length of stay, arterial dissection, and death.

Results: Fifteen patients underwent TCAR before cardiac surgery. Of these, 73.33% were men, with a median age of 65.98 years. Eighty percent of the cohort was asymptomatic, and the majority of the cohort had greater than 80% stenosis. Bridging anticoagulation treatment included aspirin and either heparin infusion (60.0%, n = 9), intravenous antiplatelet therapy such as cangrelor or eptifibatide (33.33%, n = 5), or subcutaneous enoxaparin (6.67%, n = 1). No patients experienced MI, stroke, CN injury, neck hematoma, or arterial dissection within 30 days. There were no deaths within 30 days.

Conclusion: In our initial experience with TCAR prior to cardiac surgery, there were no cerebrovascular complications, suggesting the feasibility of same admission TCAR and cardiac surgery. In our experience, a range of anticoagulation bridging therapies did not result in apparent stent thrombosis and can be employed until the cardiac surgeon deems it safe to initiate oral dual antiplatelet therapy. 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.